Dance Driven Online Registration

Registration

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DANCE DRIVEN

* 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
(Not Contact #1 or #2)*

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)

Cell #

Additional Info

Student Email

School

Grade Level

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Please enroll based on the upcoming school year for summer and fall classes. Entering your credit card does NOT mean you are enrolled in automatic tuition withdrawal. Forms for this service must be completed at the studio.

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

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

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

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

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

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

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

Disabilites

Special Needs

Allergies

Medications

Primary Doctor

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Assumption of Risk/Release of Injury

I understand that I may occur injury while participating .As the legal parent or guardian, I have volunteered my child to participate in a program under the direction of Dance Driven, which will include, but may not be limited to, dance, tumbling and physical conditioning. I understand that there are certain risks of injury to which my child may be exposed by participating in the activities offered by or at Dance Driven. I agree to accept and assume all risks related directly or indirectly from participation in activities offered by or at Dance Driven. Upon agreement, I do hereby hold harmless and release Dance Driven, and their respective agents, owners, operators, heirs, assigns, contractors, landlords, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my child's participation in this or any program conducted by or through Dance Driven.

Parents, legal guardians of minors, students and adult students waive the right to any legal action for any injury sustained on studio property resulting from normal dance activity or any other activity conducted by the student before, during or after class time

I've read the above and agree.

Payment Policy

I have read and understood the policies placed by Dance Driven.

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