South Dayton School of Dance Online Registration

Registration

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Welcome to South Dayton School of Dance! Please complete the following registration form. If you have any questions please email us at southdaytonschoolofdance@gmail.com If you are an Adult Student please list yourself as Contact #1 and as Student #1. For School and Grade please enter "N/A". Please list your emergency contact as an emergency contact and not Contact #2. Thank you!

* 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 Parent/Guardian #1 or #2)*

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Phone #*

Contact #1

Parent/Guardian #1 First Name*

Last Name *

Relationship to Student*

How Can We Contact You?

Home Phone

Work #

Cell # * Receive Text Message Notifications

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

Parent/Guardian #2 First Name

Last Name

Relationship to Student

How can we contact you?

Home Phone

Work #

Cell # * Receive Text Message Notifications

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 # Receive Text Message Notifications

Additional Info

Student Email (if applicable)

School*

Grade Level*

Special Needs ie. IEP, 504, anxiety, medical diagnoses, etc. (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

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email (if applicable)

School*

Grade Level*

Special Needs ie. IEP, 504, anxiety, medical diagnoses, etc. (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

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email (if applicable)

School*

Grade Level*

Special Needs ie. IEP, 504, anxiety, medical diagnoses, etc. (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

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email (if applicable)

School*

Grade Level*

Special Needs ie. IEP, 504, anxiety, medical diagnoses, etc. (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

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications

Additional Info

Student Email (if applicable)

School*

Grade Level*

Special Needs ie. IEP, 504, anxiety, medical diagnoses, etc. (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

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

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

eCheck/Bank Draft

Required Policies

(Show-Hide Details)