MantyDance Online Registration

Registration

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Welcome to MantyDance! Please complete the following registration form. You will review all of our policies and procedures on this registration form but you may also go to manty.dance anytime to review or print a copy of our policies and procedures as well. You may go to manty.dance and read our policies and procedures.

* 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 *

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*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

If a class you are looking for is full please hit waitlist so we can add you to a class!

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

If a class you are looking for is full please hit waitlist so we can add you to a class!

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

If a class you are looking for is full please hit waitlist so we can add you to a class!

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

If a class you are looking for is full please hit waitlist so we can add you to a class!

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

School

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

If a class you are looking for is full please hit waitlist so we can add you to a class!

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

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?

Who is your employer?

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

eCheck/Bank Draft

Required Policies

(Show-Hide Details)