Michelle Latimer Dance Academy, Inc. Online Registration

Registration

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Welcome to Michelle Latimer Dance Academy, Inc.! Please complete the following registration form shown below

* 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 *

How Can We Contact You?

Home Phone

Work #

Cell # Receive Text Message Notifications

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

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

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

Additional Info

T-Shirt Size

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*

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

Additional Info

T-Shirt Size

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*

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

Additional Info

T-Shirt Size

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*

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

Additional Info

T-Shirt Size

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*

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

Additional Info

T-Shirt Size

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

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Agreement

Students of Michelle Latimer Dance Academy (MLDA) or parent/legal guardian of student if under 18, understands and agrees that in participating in any dance classes, rehearsals or performance there is a possibility of physical injury. Student or parent/guardian agrees, therefore, to assume all risks of any such injury which might occur during any and all MLDA classes, rehearsals and performances. Student or parent/guardian exempts, releases and indemnifies MLDA, its owner, guest artists and faculty members from any and all liability claims, demands or cause of action whatsoever from any damage, loss or injury to student, parent/guardian, family member or personal property which may arise out of, or in connection with participation in any activities conducted by MLDA.
I understand and agree to the terms set forth in this Liability Waiver

I've read the above and agree.

Account in Good Standing

All dancers' accounts MUST be kept in good standing throughout the season. Automatic Payment options are offered by MLDA and are REQUIRED for any dancer registered for classes at MLDA. Failure to keep an account current will result in a dancer being pulled from classes until the account is paid in full. A dancers' account is considered in default when a balance is carried for more than 30 days. Should an account stay in default for 60 days or more a dancer is no longer allowed to take classes. If the account is brought back to good standing a dancer may begin taking classes again if enrollment is still open.

I've read the above and agree.

Pain Medicine

I hereby give permission for MLDA to dispense the following medications to my dancer if a need arises. The medications available are Tylenol and Advil. Only one tablet administered if 100 pounds or less. Please note that MLDA only has adult strength available.

I've read the above and agree.

Non-Refundable Deposit

I understand that there is a non-refundable deposit due at time of registration and that my dancers place in the program is not guaranteed until such time as the deposit has been received. An invoice will be sent regarding this deposit within 48 hours of receipt. If you do not receive the confirmation invoice please contact us to confirm your dancers placement.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

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