Wishes Dance Studio Online Registration

Registration

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Welcome to Wishes Dance Studio! We are pleased that you are joining us!

* 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*

Health Insurance Carrier

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* (format=mm/dd/yyyy)

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Skill Notes

Number Of Years In Recital

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

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Skill Notes

Number Of Years In Recital

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

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Skill Notes

Number Of Years In Recital

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

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Skill Notes

Number Of Years In Recital

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

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Skill Notes

Number Of Years In Recital

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

VOLUNTARY PARTICIPATION

As a Wishes Dance Studio student or parent/guardian of a Wishes Dance Studio student, I have voluntarily chosen and requested my minor child to participate in the dance training offered by Wishes Dance Studio and that I (and/or my minor child) am/are under no obligation to continue such dance training.

I've read the above and agree.

ASSUMPTION OF RISK

Dance training and related activities carry certain risks that can result in injury, both minor and major. I voluntarily assume and accept all risks and potential hazards involved in dance training and related activities provided by Wishes Dance Studio. I understand that I am strongly advised to obtain comprehensive medical insurance prior to engaging in this activity.

I've read the above and agree.

RELEASE

In consideration of the opportunity afforded me (my minor child) to participate in the dance training offered by Wishes Dance Studio, I am waiving the right to file any claim or lawsuit against Wishes Dance Studio, its employees, members, officers, directors, agents or representatives for any injury or damage resulting from my (or my minor child's) participation in this dance training or all related activities, including, but not limited to, claim of injury, damage to officers, directors, agents or representatives. In addition Wishes Dance Studio reserves the right to take pictures and video to be used for marketing efforts.

I've read the above and agree.

PAYMENT & LATE FEE

Payment is due (in full) to Wishes Dance Studio at the time of registration. Your card on file will be charged at the time of registration. If your card is declined or if the customer fails to pay by the first class, a $25 late fee will be charged to the student's account. If payment is not received by the start of the second class, an additional $25 late fee will be charged every week until full payment is received, while the student may not be allowed to attend class. The account will be flagged and the student will not be eligible to participate in any future classes with Wishes Dance Studio until the account is settled.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

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*