Etudes de Ballet & Co. Online Registration

Registration

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Welcome to Études de Ballet. Please complete the following form. There is a required registration fee that will be charged to the card on file once the form has been submitted. Thank You.

* 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 (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 # *

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Etudes de Ballet & Co.. Standard message and data rates apply. Reply STOP to opt out

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*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Etudes de Ballet & Co.. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities (If NONE write NONE)*

Special Needs (If NONE write NONE)*

Allergies (if NONE write NONE)*

Medications (if NONE write NONE)*

Primary Doctor

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Etudes de Ballet & Co.. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities (If NONE write NONE)*

Special Needs (If NONE write NONE)*

Allergies (if NONE write NONE)*

Medications (if NONE write NONE)*

Primary Doctor

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Etudes de Ballet & Co.. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities (If NONE write NONE)*

Special Needs (If NONE write NONE)*

Allergies (if NONE write NONE)*

Medications (if NONE write NONE)*

Primary Doctor

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Etudes de Ballet & Co.. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities (If NONE write NONE)*

Special Needs (If NONE write NONE)*

Allergies (if NONE write NONE)*

Medications (if NONE write NONE)*

Primary Doctor

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Etudes de Ballet & Co.. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Disabilities (If NONE write NONE)*

Special Needs (If NONE write NONE)*

Allergies (if NONE write NONE)*

Medications (if NONE write NONE)*

Primary Doctor

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

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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)

Who is your employer?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies

(Show-Hide Details)