Chickee's Dance World Online Registration

Registration

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Welcome to Chickee's Dance World! We provide a comfortable atmosphere for which the students feel at home therefore making dance more easily accessible. All of us at CDW feel it is necessary to be concerned not only with dance instruction but with the students' level of self-confidence. Dance can be one of the most rewarding activities when more attention is given to each student. We promise to provide memories that will last a lifetime along with self-confidence, respect and a love of dance!

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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*

Home or 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

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)

Cell #

Additional Info

Student Email

School

Disabilites

Special Needs

Allergies

Medications

Please click on the Search button below, then choose the class. You will notice an increased registration fee which includes a non-refundable costume deposit.

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

School

Disabilites

Special Needs

Allergies

Medications

Please click on the Search button below, then choose the class. You will notice an increased registration fee which includes a non-refundable costume deposit.

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

School

Disabilites

Special Needs

Allergies

Medications

Please click on the Search button below, then choose the class. You will notice an increased registration fee which includes a non-refundable costume deposit.

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

School

Disabilites

Special Needs

Allergies

Medications

Please click on the Search button below, then choose the class. You will notice an increased registration fee which includes a non-refundable costume deposit.

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

School

Disabilites

Special Needs

Allergies

Medications

Please click on the Search button below, then choose the class. You will notice an increased registration fee which includes a non-refundable costume deposit.

Enroll in Classes

Select Class *

Add Another Student

Required Policies and Agreements

"I have enrolled myself/my child in the dance program offered by Chickee's Dance World. I recognize that the program may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various dance activities. I hereby affirm that my child/myself is in good physical condition and does not suffer from any known disability or condition which would prevent or limit the participation in this dance program."

I've read the above and agree.

"In consideration of my/my child's participation in this program I, hereby release Chickee's Dance World and its agents from any claims, demands and causes of action as a result of my voluntary participation and enrollment."

I've read the above and agree.

"I fully understand that I/ my child may injure myself/his or herself as a result of enrollment and subsequent participation in this program and I, hereby release Chickee's Dance World and its agents from any liability now or in the future for conditions that may be obtained. These conditions may include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat prostration, injuries to knees, injuries to back, injuries to foot or any other illness or soreness that I may incur, including death.".

I've read the above and agree.

"I give permission to Chickee's Dance World to use pictures and videos for promotional purposes on chickeesdanceworld.com, Facebook, Twitter & Instagram."

I've read the above and agree.

I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS.

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 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