The Belfry Centre for Spirituality and Arts - SBarts Online Registration

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Welcome to The Belfry Centre for Spirituality and Arts - SBarts! Please complete the following registration form.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information /Información Familiar

Family / Familia Last Name*

Where do you live?

Home Address*

City*

State / Estado*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info / Información de contacto de emergencia*

Health Insurance Carrier / Compañía de seguros de salud*

DISCOUNT CODE #

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*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

Grade Level*

Disabilities (Write NONE if that is the case)*

Special Needs (Write NONE if that is the case)*

Allergies (Write NONE if that is the case)*

Medications (Write NONE if that is the case)*

Primary Doctor*

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*

Additional Info

T-Shirt Size*

Grade Level*

Disabilities (Write NONE if that is the case)*

Special Needs (Write NONE if that is the case)*

Allergies (Write NONE if that is the case)*

Medications (Write NONE if that is the case)*

Primary Doctor*

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

T-Shirt Size*

Grade Level*

Disabilities (Write NONE if that is the case)*

Special Needs (Write NONE if that is the case)*

Allergies (Write NONE if that is the case)*

Medications (Write NONE if that is the case)*

Primary Doctor*

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*

Additional Info

T-Shirt Size*

Grade Level*

Disabilities (Write NONE if that is the case)*

Special Needs (Write NONE if that is the case)*

Allergies (Write NONE if that is the case)*

Medications (Write NONE if that is the case)*

Primary Doctor*

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

T-Shirt Size*

Grade Level*

Disabilities (Write NONE if that is the case)*

Special Needs (Write NONE if that is the case)*

Allergies (Write NONE if that is the case)*

Medications (Write NONE if that is the case)*

Primary Doctor*

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

Account Information

e-Payment Schedule*

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State / Estado

Zip*

Registration

Referral Information

Family Information /Información Familiar

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

Account Information

Credit Card

Required Policies

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