5th St. Center for Dance LLC Online Registration

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Welcome to 5th St. Center for Dance ! Please complete the following registration form! Classes start Monday September 9, 2024! Please be sure to access your account through the Parent Portal after you register and enroll. Please enter only one form of payment Credit Card or ACH. Accounts must be paid in full within 48 hours of registering. If you have any questions about levels/classes please email 5streetnews@gmail.com

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Referral Information

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Referral Name

Family Information

Family Last Name*

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Home Address*

City*

State*

Zip*

Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone

Work #

Cell # *

Portal Access (your email is your login)

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Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

Cell #

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Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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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

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Are you a returning student?*

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*

Additional Info

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

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Are you a returning student?*

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*

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Student Gender*

Birth Date*

Additional Info

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Are you a returning student?*

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*

Additional Info

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Are you a returning student?*

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

Enroll in Classes

Select Class *

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Payment Information

Credit Card

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Exp Year

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Name as it appears on card

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Address Line 2

City

State

Zip

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Registration

Referral Information

Family Information

Where do you live?

Contact #1

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Student #1

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