American Dance Studio Online Registration

Registration

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Welcome to American Dance Studio! If you are signing up for a TRIAL CLASS , please complete all of the below information, select the classes you would like to trial, and select the Submit Registration button at the bottom of the page.

* 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 *

Type*

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

Type

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*

Student Gender*

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

Cell # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Student Tee shirt size*

Please click on the Search button below, then choose the class. For Trial Class Registration: After you've selected the class, please change the drop down to Yes for Trial Class registration.

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 # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Student Tee shirt size*

Please click on the Search button below, then choose the class. For Trial Class Registration: After you've selected the class, please change the drop down to Yes for Trial Class registration.

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 # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Student Tee shirt size*

Please click on the Search button below, then choose the class. For Trial Class Registration: After you've selected the class, please change the drop down to Yes for Trial Class registration.

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 # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Student Tee shirt size*

Please click on the Search button below, then choose the class. For Trial Class Registration: After you've selected the class, please change the drop down to Yes for Trial Class registration.

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 # Receive Text Message Notifications

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

Immunization Notes

Student Tee shirt size*

Please click on the Search button below, then choose the class. For Trial Class Registration: After you've selected the class, please change the drop down to Yes for Trial Class registration.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

(Show-Hide Details)

Liability

I've read the above and agree.

Medical

I've read the above and agree.

Recital

I've read the above and agree.

Payment Terms

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

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

Registration

Referral Information

Family Information

Where do you live?

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

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 and Agreements (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies and Agreements

(Show-Hide Details)