Heartbeat Dance Center Online Registration

Registration

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Welcome to Heartbeat Dance Center! Please complete this online registration form to participate in our dance programs. Please log into our Customer Portal to pay with your saved payment method or contact our office for payment options. If you are interested in a trial class, please submit this form without selecting a class and send an email dance@heartbeatdance.com with your request. We look forward to dancing with you!

* 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)*

Contact #1

Contact #1 First Name*

Last Name *

Relation To Student*

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*

Relation To Student*

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

T-Shirt Size

School*

Grade Level*

Physical Restrictions

Allergies*

Medications (Leave blank if NONE)

HDC Competition Dancer? Yes/No*

Please click on the Search button below, then choose the class. If you have trouble finding the class you are looking for, please contact us for assistance.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Physical Restrictions

Allergies*

Medications (Leave blank if NONE)

HDC Competition Dancer? Yes/No*

Please click on the Search button below, then choose the class. If you have trouble finding the class you are looking for, please contact us for assistance.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Physical Restrictions

Allergies*

Medications (Leave blank if NONE)

HDC Competition Dancer? Yes/No*

Please click on the Search button below, then choose the class. If you have trouble finding the class you are looking for, please contact us for assistance.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Physical Restrictions

Allergies*

Medications (Leave blank if NONE)

HDC Competition Dancer? Yes/No*

Please click on the Search button below, then choose the class. If you have trouble finding the class you are looking for, please contact us for assistance.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Physical Restrictions

Allergies*

Medications (Leave blank if NONE)

HDC Competition Dancer? Yes/No*

Please click on the Search button below, then choose the class. If you have trouble finding the class you are looking for, please contact us for assistance.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

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*

Jackrabbit Technologies' class management platform & registration portal is trusted by 1000s of
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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

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

Credit Card

Required Policies

(Show-Hide Details)