Central Mississippi Dance Online Registration

Registration

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Welcome to Central Mississippi Dance! Please complete the following Registration Form. If you would like to enroll into classes, you will be redirected to the class enrollment page. You will then select your classes and complete the online enrollment process.

* 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)*

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

T-Shirt Size*

School*

Grade Level*

Disabilities (Write NONE if none known)

Special Needs (Write NONE if none known)

Allergies (Write NONE if none known)*

Medications (Write NONE if none known)

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 #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities (Write NONE if none known)

Special Needs (Write NONE if none known)

Allergies (Write NONE if none known)*

Medications (Write NONE if none known)

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 #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities (Write NONE if none known)

Special Needs (Write NONE if none known)

Allergies (Write NONE if none known)*

Medications (Write NONE if none known)

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 #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities (Write NONE if none known)

Special Needs (Write NONE if none known)

Allergies (Write NONE if none known)*

Medications (Write NONE if none known)

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 #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities (Write NONE if none known)

Special Needs (Write NONE if none known)

Allergies (Write NONE if none known)*

Medications (Write NONE if none known)

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

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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

Required Policies

(Show-Hide Details)