Lynch Dance Institute Online Registration

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Welcome! On behalf of our entire team, we are thrilled you have taken the first step in joining the LDI family! Our dedicated, passionate, and unparalleled staff of professionals look forward to meeting you and showing you the tremendous outcomes that are achieved when you invest in excellence.

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Referral Information

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Referral Name

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Home Address*

City*

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Zip*

Primary Phone*

Additional Info

Emergency Contact Info<br/>(Not Contact #1 or #2) Name and phone number*

Health Insurance Carrier*

Contact #1

Contact #1 First Name*

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Type

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Employer

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Contact #2

Contact #2 First Name

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Confirm Email

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Employer

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Student #1

Student's First Name*

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Birth Date*

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Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please take a moment to review your students letter of recommendation as those are the classes and performance opportunities in which you are eligible and encouraged to enroll.

Please click on the "Select Class" button below, then choose your classes.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

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Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please take a moment to review your students letter of recommendation as those are the classes and performance opportunities in which you are eligible and encouraged to enroll.

Please click on the "Select Class" button below, then choose your classes.

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 (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please take a moment to review your students letter of recommendation as those are the classes and performance opportunities in which you are eligible and encouraged to enroll.

Please click on the "Select Class" button below, then choose your classes.

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 (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please take a moment to review your students letter of recommendation as those are the classes and performance opportunities in which you are eligible and encouraged to enroll.

Please click on the "Select Class" button below, then choose your classes.

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 (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Please take a moment to review your students letter of recommendation as those are the classes and performance opportunities in which you are eligible and encouraged to enroll.

Please click on the "Select Class" button below, then choose your classes.

Enroll in Classes

Select Class *

Add Another Student

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Exp Year *

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Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

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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

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