Dance IQ Online Registration

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1. Month-to-Month Clients- Tuition beginning July 1st, 2024, will be $100 for one class a week (multi-class discounts available). 2. NEW Members- 13 Month contract: August to August 31st, at registration, 1st and last month plus reg fee. For example, $85 + $85= $170 + $50 reg. fee= $220 ( 1 class per week/per month). If registering for Fall by June 15th NO FEE.

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Referral Information

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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)*

Photo Release? Yes or No*

Membership Contract? Yes or No*

Family, Core,Per., REC.,Adult

Non-Membership NO discount

Contact #1

Contact #1 First Name*

Last Name *

Type

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Home Phone

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

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Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

Cell #

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 (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies -Yes/No. If yes what are the allergies?*

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies -Yes/No. If yes what are the allergies?*

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

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Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies -Yes/No. If yes what are the allergies?*

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

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Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies -Yes/No. If yes what are the allergies?*

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

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Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies -Yes/No. If yes what are the allergies?*

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

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Comments

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Account Information

Payment Schedule-1st of the month

Membership Type-family, company, performance, recreational, adult single,

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

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Student #2 (Show-Hide Details)

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