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.

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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*

New Family (yes or no) ?*

Virtual-Only Opt.(yes or no)?*

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

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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*

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Registration

Referral Information

Family Information

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

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

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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