Motion House Dance Company Online Registration

Registration

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Welcome to Motion House Dance Company! Please complete the following registration form. To have your payments automatically deducted each month YOU MUST check "1st of Month" in the billing section. 3% charge for all credit/debit card payments.

* 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*

Primary Phone*

Additional Info

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

Health Insurance Carrier*

Contact #1

Contact #1 First Name*

Last Name *

Type

How Can We Contact You?

Home Phone

Work #

Cell # Receive Text Message Notifications

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications

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*

Allergies*

Medications*

Primary Doctor*

Immunization Notes

Please click on the Search button below, then choose the class. If you have any questions for proper class placement please email us.

Enroll in Classes

Select Class *

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*

Allergies*

Medications*

Primary Doctor*

Immunization Notes

Please click on the Search button below, then choose the class. If you have any questions for proper class placement please email us.

Enroll in Classes

Select Class

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*

Allergies*

Medications*

Primary Doctor*

Immunization Notes

Please click on the Search button below, then choose the class. If you have any questions for proper class placement please email us.

Enroll in Classes

Select Class

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*

Allergies*

Medications*

Primary Doctor*

Immunization Notes

Please click on the Search button below, then choose the class. If you have any questions for proper class placement please email us.

Enroll in Classes

Select Class

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*

Allergies*

Medications*

Primary Doctor*

Immunization Notes

Please click on the Search button below, then choose the class. If you have any questions for proper class placement please email us.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

Please fill out ONE of the following Payment Methods

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

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)

Who is your employer?

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

eCheck/Bank Draft

Required Policies

(Show-Hide Details)