Step In Time Dance Academy, LLC Online Registration

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Welcome to Step In Time Dance Academy, LLC! Please complete the following registration form. Monthly Discounts 1 Class per/ week: No Discount, 2 Classes per / week: $10 Discount, 3 Classes per/ week: $40 Discount, 4 Classes per/ week: $70 Discount , 5 Classes per/ week: $100 Discount, Unlimited Classes per/ week: $130 Discount

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Referral Information

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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

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

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size*

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Immunization Notes

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*

Additional Info

Student Email

T-Shirt Size*

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Immunization Notes

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*

Additional Info

Student Email

T-Shirt Size*

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Immunization Notes

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*

Additional Info

Student Email

T-Shirt Size*

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Immunization Notes

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*

Additional Info

Student Email

T-Shirt Size*

School

Grade Level

Transportation

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)

Immunization Notes

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

Enroll in Classes

Select Class

Add Another Student

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Exp Year *

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Address Line 2

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Zip*

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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)

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

Additional Info

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I Agree to All of the Above

Questions or Concerns

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Required Policies

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