Academy Dance Center Online Registration

Registration

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Welcome to Academy Dance Center, LLC! 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)*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy Dance Center. Standard message and data rates apply. Reply STOP to opt out

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 # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy Dance Center. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy Dance Center. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Previous Dance Experience :*

If so, number of years?

Previous Studios/Instructors:

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy Dance Center. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Previous Dance Experience :*

If so, number of years?

Previous Studios/Instructors:

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy Dance Center. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Previous Dance Experience :*

If so, number of years?

Previous Studios/Instructors:

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy Dance Center. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Previous Dance Experience :*

If so, number of years?

Previous Studios/Instructors:

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from Academy Dance Center. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

T-Shirt Size*

School*

Grade Level*

Special Needs (Leave blank if NONE)

Previous Dance Experience :*

If so, number of years?

Previous Studios/Instructors:

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule*

Please fill out CREDIT CARD Payment Method

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

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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)