Judy's Dance Academy Inc Online Registration

Registration

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Welcome to Judy's Dance Academy! If you are new to us, please fill out the information below and press submit when complete. If you are a current/past student, please register via the link above. Please note we do not accept payment by EFT or echeck bank withdrawal. We only accept cash, check, debit or credit cards. To complete the registration process, you must click on your “cart” and “checkout.” Full payment of your balance is due at time of checkout to hold your place in classes.

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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 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 Judy's Dance Academy Inc. 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

Contact #2

Contact #2 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 Judy's Dance Academy Inc. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School

Grade Level*

Disabilities (If none, type NONE)

Special Needs (If none, type NONE)

Allergies (If none, type NONE)*

Medications (If none, type NONE)*

Additional Medical Info

Permission to use Photos Y/N*

Permission to use Videos Y/N*

Please remember some of our classes are by age. If you do not fall in the age parameters you will not be able to sign up for that particular class. Please email us at judysdanceacademy@gmail.com if you need help.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School

Grade Level*

Disabilities (If none, type NONE)

Special Needs (If none, type NONE)

Allergies (If none, type NONE)*

Medications (If none, type NONE)*

Additional Medical Info

Permission to use Photos Y/N*

Permission to use Videos Y/N*

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School

Grade Level*

Disabilities (If none, type NONE)

Special Needs (If none, type NONE)

Allergies (If none, type NONE)*

Medications (If none, type NONE)*

Additional Medical Info

Permission to use Photos Y/N*

Permission to use Videos Y/N*

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School

Grade Level*

Disabilities (If none, type NONE)

Special Needs (If none, type NONE)

Allergies (If none, type NONE)*

Medications (If none, type NONE)*

Additional Medical Info

Permission to use Photos Y/N*

Permission to use Videos Y/N*

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School

Grade Level*

Disabilities (If none, type NONE)

Special Needs (If none, type NONE)

Allergies (If none, type NONE)*

Medications (If none, type NONE)*

Additional Medical Info

Permission to use Photos Y/N*

Permission to use Videos Y/N*

Enroll in Classes

Select Class *

Add Another Student

Required Policies

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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*

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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

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

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Questions or Concerns

Payment Information

Credit Card

Required Policies

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