Centre Stage Dance Academy Online Registration

Welcome to Centre Stage Dance Academy! We are thrilled you are joining us! Contact us via call or text at 256-245-2453 OR email us at welcome@csdadance.com

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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*

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

Who is your employer?

Employer*

Employer Phone*

Employer Notes

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

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (If none enter N/A)*

Special Needs (If none enter N/A)*

Allergies (If none enter N/A)*

Medications (If none enter N/A)*

Primary Doctor*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (If none enter N/A)*

Special Needs (If none enter N/A)*

Allergies (If none enter N/A)*

Medications (If none enter N/A)*

Primary Doctor*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (If none enter N/A)*

Special Needs (If none enter N/A)*

Allergies (If none enter N/A)*

Medications (If none enter N/A)*

Primary Doctor*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (If none enter N/A)*

Special Needs (If none enter N/A)*

Allergies (If none enter N/A)*

Medications (If none enter N/A)*

Primary Doctor*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (If none enter N/A)*

Special Needs (If none enter N/A)*

Allergies (If none enter N/A)*

Medications (If none enter N/A)*

Primary Doctor*

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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*

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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

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Questions or Concerns

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