Ballethnic Academy of Dance Online Registration

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Thank you for choosing Ballethnic Academy of Dance! Our online registration process is simple and convenient. Please let us know if there is anything further we can do to assist you.

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Referral Information

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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*

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Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

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Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Please click on the Search button below, then choose the class.

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Please click on the Search button below, then choose the class.

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Student #3 (Show-Hide Details)

Student's First Name*

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Additional Info

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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Medications (Leave blank if NONE)*

Please click on the Search button below, then choose the class.

Enroll in Classes

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Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Please click on the Search button below, then choose the class.

Enroll in Classes

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Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Please click on the Search button below, then choose the class.

Enroll in Classes

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Comments

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Account Information

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Monthly payment on the 5th or the 20th?*

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*

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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?

Who is your employer?

Student #1

Additional Info

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Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

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