2025/2026 Registration Form
Email
example@example.com
REGISTRATION DETAILS
Registration Type: Student - New, Student - Returning, Family (2 or more children), Adult
Classes: 1 class, 2 classes
Payment options: Monthly, Upfront - 10% Discount
Payment Plan: One time upfront for the year
Registration Type
*
New Student - $40
Student - Returning, $30
Family Registration 2 more children, $70
Adult
PARENT / GUARDIAN
Number of Children
*
Please Select
1
2
3
4
5
Number of Classes Per Student (Choose 1). October - June Classes
*
1 Class
2 Classes
Payment Plan Type (Choose 1)
*
Monthly - 1 Class Per Month, $100 per month per child
Monthly - 2 Classes Per Month, $140 per month per child
One Time Upfront - 1 Class Per Month, $810 per child
One Time Upfront - 2 Classes Per Month, $1134 per child
Parent Name
*
Parent Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent / Guardian Email
*
Email address that will receive class links, studio updates general information ***
Parent / Guardian Phone Number
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
STUDENT 1 INFORMATION
Student Name
*
Age
*
Date of Birth
*
MM/DD/YYYY
Gender
*
Male
Female
N/A
Allergies
*
Physical Restrictions
*
1st Class Selection
Capoeira
African Dance
Yoga
Modern
2nd Class Selection
Capoeira
African Dance
Yoga
Modern
STUDENT 2 INFORMATION (Click here to enter)
Student Name
*
Age
*
Date of Birth
*
MM/DD/YYYY
Gender
*
Male
Female
N/A
Allergies
*
Physical Restrictions
*
1st Class Selection
Capoeira
African Dance
Yoga
Modern
2nd Class Selection
Capoeira
African Dance
Yoga
Modern
STUDENT 3 INFORMATION (Click here to enter)
Student Name
*
Age
*
Date of Birth
*
MM/DD/YYYY
Gender
*
Male
Female
N/A
Allergies
*
Physical Restrictions
*
1st Class Selection
Capoeira
African Dance
Yoga
Modern
2nd Class Selection
Capoeira
African Dance
Yoga
Modern
STUDENT 4 INFORMATION (Click here to enter)
Student Name
*
Age
*
Date of Birth
*
MM/DD/YYYY
Gender
*
Male
Female
N/A
Allergies
*
Physical Restrictions
*
1st Class Selection
Capoeira
African Dance
Yoga
Modern
2nd Class Selection
Capoeira
African Dance
Yoga
Modern
STUDENT 5 INFORMATION (Click here to enter)
Student Name
*
Age
*
Date of Birth
*
MM/DD/YYYY
Gender
*
Male
Female
N/A
Allergies
*
Physical Restrictions
*
1st Class Selection
Capoeira
African Dance
Yoga
Modern
2nd Class Selection
Capoeira
African Dance
Yoga
Modern
ADULT CLASS REGISTRATION (Click here to enter)
Adult Name
*
Adult Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Adult Email
*
Email address that will receive class links, studio updates general information ***
Adult Phone Number
*
Adult Emergency Contact Name
*
Adult Emergency Contact Phone Number
*
Adult Class Selection
Capoeira
African Dance
Yoga
Modern
Yoga and Modern
Adult Class Selection
*
Capoeira
African Dance
Yoga
Modern
Yoga and Modern
PAYMENT DETAILS
Total Due at Registration
Select your Payment Option
*
Select ONE
Zelle By Email (Umojadance@aol.com)
Credit Card via Square ($3.00 extra charge)
Debit Card
Cash App $Umojanitya
Cash
Please submit your payment AFTER you submit this form.
WAIVER / RELEASE
WAIVER /RELEASE
The participant agrees and understands that Umoja Dance Company carries insurance covering its legal liability. The participant accepts all risks of participating in a dance class. The participant will not make a claim against or sue the Umoja Dance Company or any of its officers or employees for injury or damage resulting from participation in the class. It is mutually agreed upon that the participant is considered to be in good condition to participate in the class.
The participant gives full permission for Umoja Dance Studio to use pictures or video from class and/or performances for advertising purposes. The participant understands that his/her name will not be used.
The participant has read the "Welcome Letter". The participant will adhere to the rules otherwise will face dismissal from the studio.
Link to Welcome Letter.
The participant understands: NO REFUNDS and NO EXCHANGES.
The participant understands Registration Fees are due at the time this form is completed.
The participant has read the Tuition Rates & Payment Information and agrees to comply with its policies. The participant understands that tuition is due on the first class of every month and that a $20 late Fee will be applied to any delinquent payments Tuition is required every month regardless of attendance. Monthly tuition payments may not be skipped because of non-attendance. NO EXCEPTION.
Signature
*
Date
-
Month
-
Day
Year
Date
Submit
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