Wheaton Studio of Dance Online Registration

Registration

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Welcome to the Wheaton Studio of Dance! We are beginning our 61st year under its Artistic Director Shannon Rush-Locke. We, as one of the largest dance studios in the Metropolitan Area, pride ourselves in good dance technique, solid dance routines presented on a professional level, good class conduct and individual attention to the strengths and weaknesses of each student. We are looking forward to a great year of dancing.

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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
(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

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

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Skill Notes

Dress Code: Black leotard, pink dance tights, pink ballet shoes, black tap shoes. All other classes (jazz, hip-hop, tap, contemporary) may wear any color leotard, tights, and jazz pants if desired. Dance shoes (including sneakers) should not be worn outside. Registration: Every family must pay a yearly registration fee of $45 Payment: All tuition payments are due the 1st of every month, anything received after the 7th must include a $15 late fee.

Enroll in Classes

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Cell #

Additional Info

Student Email

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Skill Notes

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

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Skill Notes

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

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Skill Notes

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

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Skill Notes

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Waiver of Liability

I (parent/guardian) hereby give my child permission to dance at the Wheaton Studio of Dance. I waive the rights to any legal action against Wheaton Studio of Dance for any injury sustained on studio property or any Wheaton Studio of Dance event. I understand that I am enrolling my dancer in a program of physical activity and have agreed that my student is in good physical condition and does not suffer from any disability that would prevent or limit participation in this dance program.

I've read the above and agree.

Medical Release Form

I (parent/guardian) hereby give permission for any and all medical attention to be administered to my child in the event of accident, injury, sickness, etc., under the direction of the physician listed on my registration form or at any necessary emergency facility, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment.

I've read the above and agree.

Photo Release Form & Agreements

I give full rights to the Wheaton Studio of Dance and its staff to use photos and video images of me or my child to use for promotional purposes of the Wheaton Studio of Dance only. Photos and videos will be used in brochures, websites, advertisements, and other promotional material created by the studio. Photos may appear with or without names in press releases and other print advertising. I have read, understand and agree to the above waiver of liability, medical and photo releases. I have also read and understand the "Wheaton Studio of Dance Policies and Information." I understand I will be held responsible for all tuition payments, costume payments, and late fees as listed.

I've read the above and agree.

I Agree to All of the Above

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