Cohesion Dance Project Online Registration

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Welcome to Cohesion Dance Project! Please complete the following registration form.
All information collected on this registration form will be used for classes and events at Cohesion Dance Project and will not be sold or given to any third party.

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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*

Primary Phone*

Additional Info

Emergency Contact: Name, Phone, Relationship*

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

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*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Physical or medical conditions/restrictions (leave blank if none)

Special Needs (leave blank if none)

Allergies (leave blank if none)

Photo Release (Y/N)*

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Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Physical or medical conditions/restrictions (leave blank if none)

Special Needs (leave blank if none)

Allergies (leave blank if none)

Photo Release (Y/N)*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Physical or medical conditions/restrictions (leave blank if none)

Special Needs (leave blank if none)

Allergies (leave blank if none)

Photo Release (Y/N)*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Physical or medical conditions/restrictions (leave blank if none)

Special Needs (leave blank if none)

Allergies (leave blank if none)

Photo Release (Y/N)*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Physical or medical conditions/restrictions (leave blank if none)

Special Needs (leave blank if none)

Allergies (leave blank if none)

Photo Release (Y/N)*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

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Required Policies

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Questions or Concerns

Comments

Payment Information

Account Information

I would like my card ran this day of the month: 1st, 5th

Monthly, Full Session

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

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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

Account Information

Credit Card

Required Policies

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