Centre Stage Dance Academy Online Registration

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Welcome to Centre Stage Dance Academy! We are thrilled you are here and cannot wait for a FABULOUS summer of dancing! Please complete the registration form below to begin registration for summer. If you are interested in a class that is full, you may complete this registration form or contact our office staff to be placed on a waiting list. **(256) 245-2453 ** centrestagedanceacademyal@gmail.com

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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*

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Additional Info

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

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Home Phone

Work #

Cell # *

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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 First Name

Last Name

Type

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Home Phone

Work #

Cell #

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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

School*

Grade Level*

Disabilities (If none enter N/A)*

Special Needs (If none enter N/A)*

Allergies (If none enter N/A)*

Medications (If none enter N/A)*

Primary Doctor*

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* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (If none enter N/A)*

Special Needs (If none enter N/A)*

Allergies (If none enter N/A)*

Medications (If none enter N/A)*

Primary Doctor*

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* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (If none enter N/A)*

Special Needs (If none enter N/A)*

Allergies (If none enter N/A)*

Medications (If none enter N/A)*

Primary Doctor*

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* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (If none enter N/A)*

Special Needs (If none enter N/A)*

Allergies (If none enter N/A)*

Medications (If none enter N/A)*

Primary Doctor*

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* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilities (If none enter N/A)*

Special Needs (If none enter N/A)*

Allergies (If none enter N/A)*

Medications (If none enter N/A)*

Primary Doctor*

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

Enroll in Classes

Select Class

Add Another Student

Required Policies

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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

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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)

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Student #4 (Show-Hide Details)

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Student #5 (Show-Hide Details)

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