Beth Walsh Dance Centre Online Registration

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Welcome to Beth Walsh Dance Centre! We look forward to meeting your child's Dance needs. Please complete the following registration form. Any questions regarding class placement or tuition fees please contact Miss Beth at tinsleydance@aol.com for assistance. #keepondancin

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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<br/>(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

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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)

Additional Info

Student Email*

T-Shirt Size

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Please click on the Search button below, then choose the class. Classes are grouped by Age and style... Preschool- Adult ... Competition Program offered in Pre-teen, Junior and Senior Class levels with consent of Miss Beth...email her at tinsleydance@aol.com for more information. Students may enroll in competition classes with Miss Beth's approval if they are at the appropriate skill level and are not interested in participating in competitions at this time.

Enroll in Classes

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email*

T-Shirt Size

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email*

T-Shirt Size

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email*

T-Shirt Size

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email*

T-Shirt Size

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Enroll in Classes

Select Class

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Required Policies and Agreements

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Lilabilty

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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*

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)

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

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I Agree to All of the Above

Questions or Concerns

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Credit Card

Required Policies and Agreements

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