Essence Dance Academy Online Registration

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Welcome to Essence Dance Arts Academy! We believe in building dancers with integrity and passion in pursuit of excellence. Our dance instructors specialize in ballet, modern/contemporary, jazz, hip-hop, creative movement, and much more. Our dance students range from early childhood to adult. Our dance classes accommodate beginner, intermediate, and advanced dancers. Let's get started by completing this registration form.

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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*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Contact #1

Parent/Legal Guardian 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

Parent/Legal Guardian 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*

Cell #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Please click the "Select Class" button below, then choose your class/classes.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Please click the "Select Class" button below, then choose your class/classes.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Please click the "Select Class" button below, then choose your class/classes.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Please click the "Select Class" button below, then choose your class/classes.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

T-Shirt Size*

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor*

Please click the "Select Class" button below, then choose your class/classes.

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Account Information

Membership Type*

Please fill out CREDIT CARD Payment Method

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

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Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

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Student #4 (Show-Hide Details)

Additional Info

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Student #5 (Show-Hide Details)

Additional Info

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Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

eCheck/Bank Draft

Required Policies

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