Lupton Street Studios Online Registration

Registration

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Welcome to Lupton Street Studios! Once you complete your studio profile, you will be able to enroll in any of our amazing programs. **** PLEASE NOTE **** Unless otherwise stated, ALL CLASSES take place at 17 Talbot St. E. in Jarvis.

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Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

Postal Code*

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*

Birth Date*

Additional Info

Special Needs / Allergies / Medications (Leave blank if NONE)

Media Release (see below)*

MEDIA RELEASE
By typing YES in the Media Release Box (above), you give consent for your / your child(ren)'s name, photo and/or video to be used in association with Lupton Street Studios on the studio website, in the media and social media outlets.

By typing NO in the Media Release Box (above), you do not give consent for your / your child(ren)'s name, photo and/or video to be used in association with Lupton Street Studios on the studio website, in the media and social media outlets.

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

Special Needs / Allergies / Medications (Leave blank if NONE)

Media Release (see below)*

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Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

Special Needs / Allergies / Medications (Leave blank if NONE)

Media Release (see below)*

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Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

Special Needs / Allergies / Medications (Leave blank if NONE)

Media Release (see below)*

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Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

Special Needs / Allergies / Medications (Leave blank if NONE)

Media Release (see below)*

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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

Country

City

Province

Postal Code

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

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Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

Additional Info

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Student #4 (Show-Hide Details)

Additional Info

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Student #5 (Show-Hide Details)

Additional Info

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I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

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