Goh Ballet Academy Online Registration

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Welcome to Goh Ballet Academy! We are excited you have chosen to pursue dance training through our prestigious Academy.

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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*

Province/State*

Postal/ZIP Code*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

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

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*

Cell #

Additional Info

Student Email

Medications*

Physician Name*

Physician Phone #*

BC (or other) Medical # *

Student preferred pronoun

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

Medications*

Physician Name*

Physician Phone #*

BC (or other) Medical # *

Student preferred pronoun

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

Medications*

Physician Name*

Physician Phone #*

BC (or other) Medical # *

Student preferred pronoun

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

Medications*

Physician Name*

Physician Phone #*

BC (or other) Medical # *

Student preferred pronoun

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

Medications*

Physician Name*

Physician Phone #*

BC (or other) Medical # *

Student preferred pronoun

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Required Policies

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Questions or Concerns

Comments

Payment Information

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Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

Country

City

Province/State

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eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Transit # (5-digits)

Institution ID (3-digits)

Account Number

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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

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

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Questions or Concerns

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