Creative Movement Center Online Registration

Registration

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Welcome to Creative Movement Center! Please complete the following registration form. Upon completion please contact us to enroll in classes--you will NOT be able to enroll in classes online.

* 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*

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

Contact #2

Contact #2 First Name

Last Name

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

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Add Another Student

Required Policies and Agreements

Participation Waiver

I hereby certify that my child is in normal health and capable of participating safely in Creative Movement Center's
programs. I assume all risks and hazards incidental to the conduct of the program and hereby release CMC or its
instructor from any and all claims for damages and injuries which may be sustained while participating in any and all
activities connected with CMC.

I've read the above and agree.

Website/Advertising Waiver

I give my permission for Creative Movement Center to use my child's photograph or likeness on our website or in connection with any advertising or news coverage of our events. Should I decline this permission, I hereby understand that I must notify CMC by emailing hayley@creativemovementcenter.com or alerting the front desk.

I've read the above and agree.

Payment Information

Tuition is due on the 1st of each month. We accept cash, checks, credit card (Visa, Master Card, Amex, and Discover). We also offer an automatic charge option. All checks should be made payable to "CMC". Tuition is the same amount each month regardless if it is a 3, 4, or 5 week month. Tuition is based on the flat rate per year and then divided into 9 monthly payments; the monthly payment amount is shown when you register. During online registration you will be charged the first and last month tuition with a one time $20 registration fee or $25 per family. If tuition is not paid by the tenth of each month, your payment method on file will be charged.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

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*