Progressive Dance Studio Online Registration

Registration

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Welcome to Progressive Dance Studio Registration Center! Please provide your information below and click "SUBMIT" when complete. Tuition is NOT charged at this time. Tuition will be billed upon registration.

* 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*

Home or Primary Phone*

Additional Info

Emergency Contact Info

Contact #1

Contact #1 First Name*

Last Name *

Mother*

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

Father*

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* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Choose any filter to narrow your search.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Choose any filter to narrow your search.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Choose any filter to narrow your search.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Choose any filter to narrow your search.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Choose any filter to narrow your search.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Assumption of Risk & Release of Liability

In consideration of the benefits derived from PDS, and understanding fully the risks associated with dance
or any physical activity, parents / students / guardians waive on their behalf and on behalf of any heirs,
executors, administrators or successors in interest any and all claims of any nature arising from any activity
in PDS or its premises, including but not limited to dance instruction, rehearsal, training and performances
at PDS, or in any location in which PDS performs, whether caused by negligence or otherwise, foreseen or
unforeseen, and for bodily injury, property damage or loss or otherwise, that students / parents / guardians
may incur, against PDS, its successors and assigns, officers, directors, shareholders, employees and agents,
and their heirs, executors, and administrators. Additionally, students/guardians waive any and all claims
arising out of (1) the act of being transported to and from such activities by any PDS staff member or parent,
or (2) as may arise out of any other PDS events or functions, whether on the PDS premises or elsewhere.
The student(s) named on this contract does voluntarily participate in any/all PDS activities and the student
and the parent / guardian understand that certain risks are involved and waive the right to any legal action
for any injury sustained resulting from any dance activity or any other activity conducted by the student(s)
before, during or after class time.

I certify that the student(s) listed on this contract is(are) in good health and capable of participating in all
the activities and classes.

I've read the above and agree.

Payment Policies

By signing this Agreement, the parent (hereinafter "I" or "me or "my") understands that tuition is a yearly
fee and must be paid as set forth in the REGISTRATION AGREEMENT above before the student attends class.
It is PDS' regular procedure to divide annual tuition and fees into 6 total payments, with the first payment
being 30% of the total annual cost, with the remainder being divided into 5 equal payments, paid monthly.
Payments will be automatically withdrawal from my bank account or credit card. Tuition costs may be paid
in full with cash, certified funds or by credit card (Master/Visa/ Discover only). A non-refundable registration
fee of $35.00 for each student is required. My account will be charged by the 5th of each month.

* I understand that each insufficiently funded transaction will incur a $35.00 fee for bank charges
incurred. I hereby authorize PDS to electronically debit my bank account or credit card for the
amount of any NSF paper check or auto-debit transaction plus a $35.00 non-sufficient funds charge.

* I understand that students will not be allowed to participate in class if tuition payments are not
current.

* I understand that PDS corresponds with me via email and all questions or concerns regarding tuition
should be sent via email. It is my responsibility to ensure that PDS has my current email address.
PDS does not send paper or emailed statements. I understand payments are due according to the
payment schedule set forth in the Registration Agreement.

* I understand that any modifications to my payment plan will be executed through Automatic
Payment processing from my checking/savings account or credit card.

* Should I require any change to the auto payment account, I must give written notice of same,
confirmed via email to PDS by the 15th of the prior month, or I will be charged as usual on the 5th of
the month.

I've read the above and agree.

Medical Emergencies

SAFETY & EMERGENCY TREATMENT
I hereby grant PDS staff and Studio Director to give consent for any emergency medical treatment to my
child while in PDS classes or participating in any PDS activity. I hold PDS and its staff harmless in such
event. I AGREE TO PAY FOR THE COSTS OF ANY SUCH MEDICAL TREATMENT.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

Please fill out ONE of the following Payment Methods

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number