MOVEZ DANCE INC. Online Registration

Registration

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Welcome to MOVEZ DANCE INC.! Please complete the following registration form. Bienvenidos a MOVEZ DANCE INC.! Por favor complete la siguiente registracion.

* denotes required fields

Referral Information

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Cell # * Receive Text Message Notifications

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Student #1

Student's First Name*

Last Name*

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

Additional Info

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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

Por favor haga click en el boton de seleccionar para elegir la clase deseada.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

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

Additional Info

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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

Por favor haga click en el boton de seleccionar para elegir la clase deseada.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

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

Additional Info

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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

Por favor haga click en el boton de seleccionar para elegir la clase deseada.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

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

Additional Info

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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

Por favor haga click en el boton de seleccionar para elegir la clase deseada.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

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

Additional Info

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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

Por favor haga click en el boton de seleccionar para elegir la clase deseada.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

Membership Type*

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)

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

Account Information

Credit Card

eCheck/Bank Draft

Required Policies

(Show-Hide Details)