Delaware Dynamix Online Registration

Registration

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Welcome to Delaware Dynamix! We are excited to get your students enrolled! Personal information shared for registration will not be shared or sold to third parties for the purpose of marketing, and will be used solely for updates and information in regards to your business with us . Please visit our Privacy Policy for more information - https://delawaredynamix.com/privacy-policy

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Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Contact #1

Family 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

Family Contact #2 (Optional) 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

Physical Limitations or Disabilities (Leave blank if NONE)

Special Emotional/Behavioral Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Other Medical Conditions (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*

Additional Info

Physical Limitations or Disabilities (Leave blank if NONE)

Special Emotional/Behavioral Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Other Medical Conditions (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*

Additional Info

Physical Limitations or Disabilities (Leave blank if NONE)

Special Emotional/Behavioral Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Other Medical Conditions (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*

Additional Info

Physical Limitations or Disabilities (Leave blank if NONE)

Special Emotional/Behavioral Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Other Medical Conditions (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*

Additional Info

Physical Limitations or Disabilities (Leave blank if NONE)

Special Emotional/Behavioral Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Other Medical Conditions (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

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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*

Registration

Family Information

Where do you live?

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)