Kinderdance Of Michigan Online Registration

Registration

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Welcome to Kinderdance Of Michigan! We are thrilled to have your child in our educational program for the 2023-2024 school year. Please complete the following registration form. Please make sure all boxes are filled in completely so we have accurate information for communication. ALL CLASSES WILL START IN OCTOBER

* 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

Photo Release*

YES*

NO*

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*

Cell #*

Additional Info

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Photo Release*

YES*

NO*

Teacher's Name? *

Grade ? *

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

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #*

Additional Info

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Photo Release*

YES*

NO*

Teacher's Name? *

Grade ? *

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

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #*

Additional Info

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Photo Release*

YES*

NO*

Teacher's Name? *

Grade ? *

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

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #*

Additional Info

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Photo Release*

YES*

NO*

Teacher's Name? *

Grade ? *

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

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #*

Additional Info

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications (Leave blank if NONE)

Primary Doctor

Photo Release*

YES*

NO*

Teacher's Name? *

Grade ? *

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

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 CREDIT CARD Payment Method

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

Account Information

Credit Card

eCheck/Bank Draft

Required Policies

(Show-Hide Details)