The Dans Company Online Registration

Registration

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* 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 *

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

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

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

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

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

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

Add Another Student

Required Policies and Agreements

Approval Required

I understand that by enrolling a student with the studio I am agreeing to pay a $25 registration fee per student. I understand that students are not enrolled in classes until approval of enrollment is sent by the instructor of the class or the director of the studio.

I've read the above and agree.

Expectations and Guidelines

I understand that Expectations, Release from Liability and Photo Release sections listed in the The Dans Company Expectations and Guidelines document must all be signed before dances are permitted to participate in classes.

The Dans Company Expectations and Guidelines document can be downloaded here.

I've read the above and agree.

Payment

I understand the monthly fees will be due on the first class period of each month. There will be a fee applied to returned checks equivalent to that of
the financial institution. There will be a fee applied to the student's account if it is past due. Each day will add $5 to the balance.
You can pay ahead at any time. Please speak with Amanda, before the payment is due, if there is a problem fulfilling the balance.

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number