Velocity Dance Online Registration

Registration

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Welcome to Velocity Dance! Please complete the following registration form and then you may access our class portal to register your athlete!

* 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*

Virginia*

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 *

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*

School*

Grade Level*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Use the Search button below, then choose the class based on style of dance or your athlete's age.

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*

School*

Grade Level*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Use the Search button below, then choose the class based on style of dance or your athlete's age.

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*

School*

Grade Level*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Use the Search button below, then choose the class based on style of dance or your athlete's age.

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*

School*

Grade Level*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Use the Search button below, then choose the class based on style of dance or your athlete's age.

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*

School*

Grade Level*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Use the Search button below, then choose the class based on style of dance or your athlete's age.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

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

Virginia

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

Jackrabbit Technologies' class management platform & registration portal is trusted by 1000s of
dance studios , gyms , swim schools , music schools , cheer gyms , childcare centers , and more .

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

eCheck/Bank Draft

Required Policies

(Show-Hide Details)