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 your registration. If you are interested in a class that is full, you may complete this registration form or contact our office staff to be placed on a waiting list.
(574) 267-7055 • info@collierdance.com

* 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<br/>(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

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)

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Tight Size*

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

T-Shirt Size

School

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Tight Size*

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

T-Shirt Size

School

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Tight Size*

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

T-Shirt Size

School

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Tight Size*

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

T-Shirt Size

School

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Tight Size*

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

Enroll in Classes

Select Class

Add Another Student