Debra Collier's School of Dance Online Registration

Registration

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Welcome to Debra Collier's School of Dance! Please complete the registration form below to begin registration for our 2019-2020 season.

* 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 and Phone Number
(Not Contact #1 or #2)*

Active Military Family?*

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

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 #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

School

Grade Level

Allergies (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)

Cell #

Additional Info

Student Email

School

Grade Level

Allergies (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)

Cell #

Additional Info

Student Email

School

Grade Level

Allergies (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)

Cell #

Additional Info

Student Email

School

Grade Level

Allergies (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)

Cell #

Additional Info

Student Email

School

Grade Level

Allergies (Leave blank if NONE)

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

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Terms & Conditions

You must agree to the Terms & Conditions to be able to submit your registration.
Visit http://collierdance.com/terms-and-conditions to view our terms and conditions.

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Authorization Agreement

You must agree to the Payment Authorization Agreement to be able to submit your registration.
https://www.collierdance.com/authorization-agreement/

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I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

Payment Option*

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*