Perrysburg Dance Academy LLC Online Registration

Registration

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Welcome to Perrysburg Dance Academy! We are honored that you have chosen to place the dance education of your child with us. Please complete the following registration form.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Name Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info (someone other than a parent)*

Health Insurance Carrier

Contact #1

Contact #1 Parent/Guardian Information 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

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 Parent/Guardian Information First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender

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

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Medical Conditions or Disabilites

Special Needs Information

Allergies (Leave blank if NONE)

Medications (Note: we cannot dispense medication)

Primary Doctor

Number year trophy for 2019?

Additional information?

Please click on the Search button below, then choose the class you are interested in. If you have any questions regarding class placement, please contact us by email at info@perrysburgdance.com or by calling 419-874-6773.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

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

Cell #

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Transportation

Medical Conditions or Disabilites

Special Needs Information

Allergies (Leave blank if NONE)

Medications (Note: we cannot dispense medication)

Primary Doctor

Number year trophy for 2019?

Additional information?

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

T-Shirt Size

School*

Grade Level*

Transportation

Medical Conditions or Disabilites

Special Needs Information

Allergies (Leave blank if NONE)

Medications (Note: we cannot dispense medication)

Primary Doctor

Number year trophy for 2019?

Additional information?

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

T-Shirt Size

School*

Grade Level*

Transportation

Medical Conditions or Disabilites

Special Needs Information

Allergies (Leave blank if NONE)

Medications (Note: we cannot dispense medication)

Primary Doctor

Number year trophy for 2019?

Additional information?

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

T-Shirt Size

School*

Grade Level*

Transportation

Medical Conditions or Disabilites

Special Needs Information

Allergies (Leave blank if NONE)

Medications (Note: we cannot dispense medication)

Primary Doctor

Number year trophy for 2019?

Additional information?

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

Preferred Payment Date

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

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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)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

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

(Show-Hide Details)