Powell School of Dance Inc. Online Registration

Registration

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Welcome to Powell School of Dance Inc.! Please complete the Registration Form below.

* 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)*

Photo & DVD Waiver? Yes/No*

Contact #1

Contact #1 First Name*

Last Name *

Type

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

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone *

Work #

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

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

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

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

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

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

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

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

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies*

Medications (Leave blank if NONE)

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

Enroll in Classes

Select Class

Add Another Student