MacConmara Academy Online Registration

Registration

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Welcome to MacConmara Academy of Irish Dance!

* 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*

Contact #1

Contact #1 First Name*

Last Name *

Type

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

Contact #2

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*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please arrive 10 before each class. Bring a water bottle with you. Wear comfortable clothing (ie: shorts, t-shirt,) and bring shoes and socks. Please make sure your hair is pulled back.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please arrive 10 before each class. Bring a water bottle with you. Wear comfortable clothing (ie: shorts, t-shirt,) and bring shoes and socks. Please make sure your hair is pulled back.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please arrive 10 before each class. Bring a water bottle with you. Wear comfortable clothing (ie: shorts, t-shirt,) and bring shoes and socks. Please make sure your hair is pulled back.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please arrive 10 before each class. Bring a water bottle with you. Wear comfortable clothing (ie: shorts, t-shirt,) and bring shoes and socks. Please make sure your hair is pulled back.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please arrive 10 before each class. Bring a water bottle with you. Wear comfortable clothing (ie: shorts, t-shirt,) and bring shoes and socks. Please make sure your hair is pulled back.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Policies

If your account is 30 days past due, your credit card/bank account on file will be automatically charged. (per the handbook)

I've read the above and agree.

Handbook

I have read and understand the handbook.. If a copy of the handbook is needed, please contact our office manager at Macconmaraoffice@gmail.com

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number