Lakewood Dance Academy Online Registration

Registration

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Welcome to Lakewood Dance Academy!

* 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 *

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

Contact #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

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

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

Cell #

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

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

Cell #

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

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

Cell #

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

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

Cell #

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

I acknowledge that my child is participating in dance instruction given by Lakewood Dance Academy and that my child is in proper physical condition and capable of participating in related activities. I understand and agree on behalf of myself and my child, to release, hold harmless, and discharge Lakewood Dance Academy from all claims, costs, liabilities, expenses or judgments, including attorneys' fees and court costs for any occurances in connection with dance instruction. I assume all risks to my child in connection with instruction and further release Lakewood Dance Academy and its owners and employees from liability for any injury sustained by my child while he or she is participating in dance instruction, rehearsal or performance.

I've read the above and agree.

I authorize and agree that Lakewood Dance Academy may take and use photographs, video or likenesses of myself or my child, as needed for its record keeping, advertising, and promotional materials and that I have no rights to the same and will not be compensated for the same.

I've read the above and agree.

I acknowledge tuition is due by the 10th of each month, and a $10.00 late fee will be added to payments made after the 15th of each month.

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

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