THE INDUSTRY Dance Academy Online Registration

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Welcome to THE INDUSTRY Dance Academy! Please complete the following registration form. In order to enroll in classes you will need to be placed in your proper level. Please email us when you have registered and to request your free trial. If you have any further questions our email is frontdesk@theindustrydanceacademy.com We look forward to meeting you. :)

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Referral Information

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Referral Name

Family Information

Family Last Name*

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Home Address*

City*

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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*

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Cell # * Receive Text Message Notifications

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Contact #2

Contact #2 First Name

Last Name

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Confirm Email*

Student #1

Student's First Name*

Last Name*

Student Gender*

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Additional Info

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School*

Grade Level*

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Primary Doctor

Immunization Notes

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Cough, Shortness of Breath?*

Exposed to anyone w/ Covid 19?*

Sore throat, headache, chills?*

Loss of Taste or Smell?*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

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Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Do you have a fever?*

Cough, Shortness of Breath?*

Exposed to anyone w/ Covid 19?*

Sore throat, headache, chills?*

Loss of Taste or Smell?*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

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Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Do you have a fever?*

Cough, Shortness of Breath?*

Exposed to anyone w/ Covid 19?*

Sore throat, headache, chills?*

Loss of Taste or Smell?*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

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Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Do you have a fever?*

Cough, Shortness of Breath?*

Exposed to anyone w/ Covid 19?*

Sore throat, headache, chills?*

Loss of Taste or Smell?*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Do you have a fever?*

Cough, Shortness of Breath?*

Exposed to anyone w/ Covid 19?*

Sore throat, headache, chills?*

Loss of Taste or Smell?*

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Registration

Referral Information

Family Information

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Additional Info

Contact #1

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Student #1

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