Alta Dance Academy, LLC Online Registration

Registration

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Welcome to Alta Dance Academy! Please provide the information below and click Submit when complete. Credit cards are NOT charged at this time. All enrollments are considered pending until we have reviewed your registration. A $20.00 registration fee for the first student and $15.00 for additional students will be charged within 24 hours of review.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info
(Not Contact #1 or #2)*

Contact #1

Contact #1 First Name*

Last Name *

Parent/Guardian*

How Can We Contact You?

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Parent/Guardian

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Primary Doctor

Skill Notes

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Primary Doctor

Skill Notes

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Primary Doctor

Skill Notes

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Primary Doctor

Skill Notes

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Transportation

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Primary Doctor

Skill Notes

Choose any filter to begin viewing available classes.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Assumption of Risk/Release of Liability

I, the undersigned, am aware that participation in dancing is potentially dangerous and involves risk of injury. I understand that these risks include, but are not limited to injury to ligaments,muscles, tendons, bones, and other aspects of the body that may include head, neck, or spine. Due to the dangers of this activity, I understand the importance of my child's following the teacher's instructions regarding techniques, training, and other rules and agree that my child will obey these instructions. In consideration for allowing my child to participate Alta Dance Academy's activities, I hereby assume all the risks associated with the sport of dance, and I agree to release Alta Dance Academy and its employees or agents from any and all liability/responsibility which may arise in connection with my child's participation in activities at Alta Dance Academy.

I've read the above and agree.

Photo Release

I, the undersigned, do hereby grant permission to Alta Dance Academy to use the image of
my registered student(s). Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or
video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, advertising, videos, and digital images such as those on Alta Dance Academy's website, Facebook, Instagram page and the studio's Youtube channel.
By signing this form, I understand that I am giving permission for my child's image to be used in print, video, and digital media. I agree that these images may be used by Alta Dance Academy for a variety of purposes and that these images may be used without further notifying me. I do understand that the child's last name will not be used in conjunction with any video or digital images.

I've read the above and agree.

Payment Agreement

I, the undersigned, do agree to assume responsibility of all financial obligations to Alta Dance Academy, including monthly tuition cost, registration fee, and recital fee (if applicable) and understand that participation in Alta Dance Academy classes is dependent on fulfilling my financial responsibility.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*