Brick Stack Arts Center Online Registration

Registration

Already a customer? Click here to login.

PLEASE READ BEFORE BEIGINNING:

TO FINISH PAYING for your class when you hit submit, click on "Go To Customer Portal" after submitting this registration form.

If paying by CASH or CHECK, please call 508-309-4604 before filling out this form.

"Contact 1" is the payer or parent; "Student" is the class participant. If you are an adult student registering yourself, you will need to fill out both.

DONATION: only fill out the required fields.

* 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*

Primary Phone*

Additional Info

Emergency Contact Info (Please fill out Contact #1 below)*

Contact #1

Emergency Contact First Name*

Last Name *

Relationship to Student*

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

Contact #2

Emergency Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Birth Date*

Cell #*

Additional Info

Student Email*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Chosen Name*

Pronouns*

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #*

Additional Info

Student Email*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Chosen Name*

Pronouns*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #*

Additional Info

Student Email*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Chosen Name*

Pronouns*

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #*

Additional Info

Student Email*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Chosen Name*

Pronouns*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #*

Additional Info

Student Email*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Chosen Name*

Pronouns*

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

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*

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Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

(Show-Hide Details)