Five Flags Dance Academy, LLC Online Registration

Registration

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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)*

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

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

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

School

Grade Level

Transportation

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

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

Student Email

School

Grade Level

Transportation

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

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

Student Email

School

Grade Level

Transportation

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

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

Student Email

School

Grade Level

Transportation

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

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

Student Email

School

Grade Level

Transportation

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Release and Hold Harmless Agreement

I/We, the Parents or Guardians, agree to permit our child to participate in the dance program and instruction as provided by Five Flags Dance Academy, LLC.

I/We, the Parents or Guardians, do release and hold harmless Five Flags Dance Academy, LLC, its agents and employees, of and from all claims and liability by reason of any injury suffered by our child as a result of participation in the dance program, whether or not it is alleged that such injury occurred by reason of the sole fault or negligence of the said Five Flags Dance Academy, LLC, its agents or employees or in part as a result thereof.

I've read the above and agree.

Consent for Medical Treatment

I/We, the Parents or Guardians, authorize any officer/director of Five Flags Dance Academy, LLC, to consent to all necessary medical care and treatment of child whether such involves first aid, the care and treatment of a medical doctor, the emergency room or admission to a hospital.

I've read the above and agree.

Studio Policies & General Info

Studio Policies and General Info is at the Studio and available at registration. Please pick up at the Studio and can be mailed or emailed.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

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