Elektro Dance Academy Online Registration

Registration

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Welcome to Elektro Dance Academy! Please complete the following registration form.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Zip*

Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Home Phone

Work #

Cell # Receive Text Message Notifications

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*

Birth Date*

Additional Info

T-Shirt Size*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please select the correct class for you or your dancer.

Enroll in Classes

Select Another Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

T-Shirt Size*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please select the correct class for you or your dancer.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

T-Shirt Size*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please select the correct class for you or your dancer.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

T-Shirt Size*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please select the correct class for you or your dancer.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

T-Shirt Size*

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Please select the correct class for you or your dancer.

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*

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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

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)