Student Registration Form

Please provide us with the information of the primary account holder. We will send all account notifications to this person. This person should be a responsible person over 16 years of age. By completing this form you give permission to The Regency Dance Centre Ltd to hold and process your personal data. Please see our GDPR Policy for further details.

Primary Account Details

Are you registering as a:(required)

Student - IndividualStudent - CoupleParent/Guardian Please select a role

Select Course(required)

Please select a course

Primary First Name(required)

Please enter your first name

Primary Last Name(required)

Please enter your surname.

Your Date of Birth

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How did you hear about The Regency Dance Centre

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Email(required)

A valid email is required for confirmation email to be sent.

Phone

Please enter your phone number and only use numeric characters

Mobile

Please enter a valid phone number.

Address Line 1

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Town/City

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County

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Postcode

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Student Details

Please give the details of any additional students who will be registering to this course. If you are the primary account holder and also registering as a student, you do not need to provide your details again here.

Number of Additional Students

1 2 Invalid Input

Student 1 First Name

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Student 1 Last Name

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Student 1 Date of Birth

Please put the date in the format dd/mm/yyyyy e.g. 01/01/2024

Student 2 First Name

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Student 2 Last Name

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Student 2 Date of Birth

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Are there any health problems or conditions that we need to be aware of? (required)

YesNo Please let us know if there are any health conditions or problems that we need to be aware of.

Please provide us with further details about your health condition

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Our Terms and Conditions

Indicated in the space above are any health problems or conditions of which the school should be aware (such as heart, back, medical, allergy, muscular, pregnancy, diabetes, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc.). I understand that risk of injury is inherent in any physical activity and I, on behalf of myself and the above named students knowingly and voluntarily accept that risk. I hereby waive and release The Regency Dance Centre and its staff from any and all claims or damages of any kind arising from any participation in an exercise and/or dance program at The Regency Dance Centre. I further certify that the aforementioned student/students is in proper physical condition to participate in classes.

I agree that I will abide by the policies and procedures put in place by The Regency Dance Centre and understand that they are in place to ensure the safety and enjoyment of all students that attend.

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I accept the Terms and Conditions(required)

I agree You must agree to our Terms and Conditions in order to submit this form.

Student Registration Form

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