Rochester Dance Theatre, LLC Online Registration

Registration

Already a customer? Click here to login.

Welcome to Rochester Dance Theatre! Please complete the following registration form. We are excited to dance with you soon!! If you have any questions or concerns, please email: contact@rochesterdancetheatre.com or call: 585-969-3320.

* 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*

Alternate Pick-up person?

Able to text on contact #?

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*

Cell #

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Immunization Notes*

Interest In Performing? (Y/N)

Interest In Competition? (Y/N)

Please click on the Search button below. When selecting a class/program, take into consideration the experience level first and the age group second. If you are unsure of placement you can complete the form without selecting a class. Please email us to help determine placement.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Immunization Notes*

Interest In Performing? (Y/N)

Interest In Competition? (Y/N)

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Immunization Notes*

Interest In Performing? (Y/N)

Interest In Competition? (Y/N)

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Immunization Notes*

Interest In Performing? (Y/N)

Interest In Competition? (Y/N)

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Cell #

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Immunization Notes*

Interest In Performing? (Y/N)

Interest In Competition? (Y/N)

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*

Jackrabbit Technologies' class management platform & registration portal is trusted by 1000s of
dance studios , gyms , swim schools , music schools , cheer gyms , childcare centers , and more .

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

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)