The Axis Centre for Dance Education Online Registration

Registration

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Welcome to The Axis Centre for Dance Education! Please complete the following registration form.

* 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*

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)

Additional Info

T-Shirt Size

Allergies (Leave blank if NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

T-Shirt Size

Allergies (Leave blank if NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

T-Shirt Size

Allergies (Leave blank if NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

T-Shirt Size

Allergies (Leave blank if NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

T-Shirt Size

Allergies (Leave blank if NONE)

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Release of Liability

I hereby give my child, permission to train at The Axis Centre for Dance Education. I waive the right to any legal action against The Axis Centre for Dance Education for any injury sustained on studio property or at any studio event.
This release is effective for the entire period the child is enrolled at The Axis Centre of Dance Education.

I've read the above and agree.

Medical Emergencies

I hereby give permission for any and all medical attention to be administered to my child , in the event of accidents, injury, sickness, etc., 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.

Payment and Cancellation Policies

Monthly tuition is due on the 25th of the month and is considered late on the 30th. It will be automatically charged
to the credit card on file on the 29th of the month. (A valid credit card must be kept on file at all times.) Late payments
accrue a fee of $25.00. Returned checks or declined card payments can result in an additional $45.00 fee. A 15 day notice is required for all class withdrawals to avoid being billed the next month's tuition.

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*