Broadway Dance Center Online Registration

Registration

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Welcome and thank you for choosing Broadway Dance Center's Children and Teens at West 45th Street! Please fill in all fields and then click "Submit Registration Information" to complete 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

Parent/Guardian 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

Parent/Guardian 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* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (yes or no) ?*

Registered at 65th (yes or no)*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (yes or no) ?*

Registered at 65th (yes or no)*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (yes or no) ?*

Registered at 65th (yes or no)*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (yes or no) ?*

Registered at 65th (yes or no)*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (yes or no) ?*

Registered at 65th (yes or no)*

Add Another Student

Required Policies and Agreements

Payments

Your primary card on file will be charged for the first month of tuition or annual tuition (if you select that option) and the registration fee of $50 (new students only) within the week.
(Moving forward, if you selected Monthly auto-pay your card on file will be charged on the first of the month each month beginning 10/1/19. ) Costume and Showcase fees are due 12/1/19 and will be deducted automatically.

I've read the above and agree.

Tuition Notes

Tuition payments are due by the 1st of each month. If payment is not received by the 15th, a late fee of $40 will be added to your balance.
Additional Fees: Costume fees and the Showcase fee are due 12/1/19.
The last day to add or drop classes is 10/13/2019 (No refunds will be issued after this date). If dropping, please submit written notification to ctp@bwydance.com. If no notification is given, you will be responsible for the entire tuition payment. If you drop after this date, you will be charged an additional month tuition. I agree to all the policies and guidelines of the BDC Children & Teens .
For the entire list of policies and guidelines please visit our website and review the info for Children & Teens W45.
http://www.broadwaydancecenter.com/ctp/index.shtml

I've read the above and agree.

Liability

I agree that Broadway Dance Center is in no way responsible for the safekeeping of my students' personal belongings while they attend class. I also acknowledge that injury may result during instruction, including but not limited to as a result of physical contact with other students, instructors, or fixed or movable objects, or the condition of the floor. I represent that my student is medically and physically able to safely participate in dance classes, workshops, rehearsals, photo shoots and performances and to meet the physical demands thereof. We agree to assume all risks associated with participating in dance instruction, workshops, rehearsals, photo shoots and performances at or in connection with Broadway Dance Center.
Additionally, I give Broadway Dance Center permission to use my CTP students' image/video for advertising purposes on social media and print.

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

Auto-Payment Schedule*

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

Zip*