Timberlane Arts and Dance Academy Online Registration

Welcome to the Timberlane Arts and Dance Academy family! 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?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Health Insurance Carrier*

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

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

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level*

Disabilities (reply NONE if NONE)*

Special Needs (reply NONE if NONE)*

Allergies (reply NONE if NONE)*

Medications (reply NONE if NONE)*

Primary Doctor*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level*

Disabilities (reply NONE if NONE)*

Special Needs (reply NONE if NONE)*

Allergies (reply NONE if NONE)*

Medications (reply NONE if NONE)*

Primary Doctor*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level*

Disabilities (reply NONE if NONE)*

Special Needs (reply NONE if NONE)*

Allergies (reply NONE if NONE)*

Medications (reply NONE if NONE)*

Primary Doctor*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level*

Disabilities (reply NONE if NONE)*

Special Needs (reply NONE if NONE)*

Allergies (reply NONE if NONE)*

Medications (reply NONE if NONE)*

Primary Doctor*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School*

Grade Level*

Disabilities (reply NONE if NONE)*

Special Needs (reply NONE if NONE)*

Allergies (reply NONE if NONE)*

Medications (reply NONE if NONE)*

Primary Doctor*

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule*

Please fill out ONE of the 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

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)

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

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)