Iowa Dance Collective Online Registration

Registration

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Welcome to Iowa Dance Collective! Please complete the following registration form. There is a yearly nonrefundable $40 registration/insurance fee per student for regular classes. If you have any questions, please contact us at (319) 280-1262 or info@iowadancecollective.com. We can't wait to see you in class!

* 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)*

Health Insurance Carrier (Enter NONE if None)*

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

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

Student #1

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities (Write NONE if NONE)*

Special Needs (Write NONE if NONE)*

Allergies (Write NONE if NONE)*

Medications (Write NONE if NONE)*

Primary Doctor*

Immunization Notes

Please click on the Select Class button below, then choose the class.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities (Write NONE if NONE)*

Special Needs (Write NONE if NONE)*

Allergies (Write NONE if NONE)*

Medications (Write NONE if NONE)*

Primary Doctor*

Immunization Notes

Please click on the Select Class button below, then choose the class.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities (Write NONE if NONE)*

Special Needs (Write NONE if NONE)*

Allergies (Write NONE if NONE)*

Medications (Write NONE if NONE)*

Primary Doctor*

Immunization Notes

Please click on the Select Class button below, then choose the class.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities (Write NONE if NONE)*

Special Needs (Write NONE if NONE)*

Allergies (Write NONE if NONE)*

Medications (Write NONE if NONE)*

Primary Doctor*

Immunization Notes

Please click on the Select Class button below, then choose the class.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities (Write NONE if NONE)*

Special Needs (Write NONE if NONE)*

Allergies (Write NONE if NONE)*

Medications (Write NONE if NONE)*

Primary Doctor*

Immunization Notes

Please click on the Select Class 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

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?

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

Required Policies

(Show-Hide Details)