Reflexion Dance Online Registration

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Welcome to Reflexion Dance! We are so excited you're here! Please fill out the following registration form.
Sign up for fall classes here! If you would like to try a free trial class before enrolling, please fill out our trial class form at www.tinyurl.com/reflexiontrial or you can email us at info@reflexiondance.com

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Referral Information

How did you hear about us?

Referral Name

Family Information

Family/Account Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Home Phone

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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Promo/Coupon Code

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Want competition team info?

Promo/Coupon Code

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*

Additional Info

School

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Want competition team info?

Promo/Coupon Code

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*

Additional Info

School

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Want competition team info?

Promo/Coupon Code

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*

Additional Info

School

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Want competition team info?

Promo/Coupon Code

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

Enroll in Classes

Select Class

Add Another Student

Required Policies

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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*

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Registration

Referral Information

Family Information

Where do you live?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

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