Texarkana Dance Academy Online Registration

Registration

Already a customer? Click here to login.

Welcome to Texarkana Dance Academy!

* 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*

Additional Info

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

Contact #1

Contact #1 First Name*

Last Name *

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

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Immunization Notes

# years dance experience

Where did you dance?

Please click on the Search button below, then choose your classes. Fees will be adjusted according to total hours enrolled to include multiple class discounts upon receipt of your registration.

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

School*

Grade Level*

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Immunization Notes

# years dance experience

Where did you dance?

Please click on the Search button below, then choose your classes. Fees will be adjusted according to total hours enrolled to include multiple class discounts upon receipt of your registration.

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

School*

Grade Level*

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Immunization Notes

# years dance experience

Where did you dance?

Please click on the Search button below, then choose your classes. Fees will be adjusted according to total hours enrolled to include multiple class discounts upon receipt of your registration.

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

School*

Grade Level*

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Immunization Notes

# years dance experience

Where did you dance?

Please click on the Search button below, then choose your classes. Fees will be adjusted according to total hours enrolled to include multiple class discounts upon receipt of your registration.

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

School*

Grade Level*

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Immunization Notes

# years dance experience

Where did you dance?

Please click on the Search button below, then choose your classes. Fees will be adjusted according to total hours enrolled to include multiple class discounts upon receipt of your registration.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Payment Policies

1. Online registration requires a credit card or bank account and email address. Charges will be posted to your card after your registration has been reviewed and discounts applied if applicable.
2. An annual $35.00 registration fee per family is due at the time of registration and is automatically charged. This fee is only charged once at the time of registration and is non-refundable.
3. Tuition is due on the 5th of each month and is late after the 15th. A $15 late fee is applied to all past due invoices.
4. A $35 per student recital fee is due in the spring and is automatically charged to each student participating in the spring performance.
5. Payments may be made online by auto billing e-payment, through the parent portal, or in person at the office. We gladly accept the following methods of payment: Visa, MasterCard, Discover, Cash, Check
6. $100 costume deposit is due in November for Recital costumes.

I've read the above and agree.

Refunds & Credits

1. Texarkana Dance Academy reserves the right to cancel any class with insufficient registration and a refund or credit will be given for remaining classes.
2. If a student sustains an injury that does not permit them to participate over an extended period of time a credit or refund will be issued.
3. Credit will not be given for missed classes due to illness, snow days, or personal commitments. You are welcome to make-up any class missed.

I've read the above and agree.

Release of Liability

As the legal parent or guardian, I release and hold harmless Texarkana Dance Academy, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or in route to or from any of said premises. I understand that appropriate physical contact is required during the instruction of dance, and I give permission for instructors to make appropriate physical contact with me or my child for such instruction.

I've read the above and agree.

Medical Emergencies

As the legal parent or guardian, I give permission to Texarkana Dance Academy, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or conditions and/or declare the participant to be in good physical and mental health.

I've read the above and agree.

Photography Agreement

In conjunction with my participation I give permission for Texarkana Dance Academy to take and use photos and/or video images of me or my child without remuneration in connection with studio publications, website, social media, and advertising.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

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