SUMMER INTENSIVES 2017 REGISTRATION



Who may we thank for referring you? (Individual, Internet, Magazine, Facebook, etc):
STUDENT #1
First Name: Last Name:
Gender:FemaleMale       Grade Level Completed: Date of Birth:
Student Cell Phone: Student E-mail:
Home Address: City:
Zip Code: Disabilities:
Allergies (Food, medical, etc.):
Previous Dance Experience:
Please select sessions to enroll in:
Full Day Program
Session 1: June 12 - June 30Session 2: July 17 - August 4

Half Day Program
Session 1: June 12 - June 30Session 2: July 17 - August 4

Early Arrival (Monday - Friday, 8:00am) $20/week: Yes No
After Care (Monday - Friday, 4:00pm - 6:00pm) $40/week: Yes No

STUDENT #2
First Name: Last Name:
Gender:FemaleMale       Grade Level Completed: Date of Birth:
Student Cell Phone: Student E-mail:
Home Address: City:
Zip Code: Disabilities:
Allergies (Food, medical, etc.):
Previous Dance Experience:
Please select sessions to enroll in:
Full Day Program
Session 1: June 12 - June 30Session 2: July 17 - August 4

Half Day Program
Session 1: June 12 - June 30 Session 2: July 17 - August 4

Early Arrival (Monday - Friday, 8:00am) $20/week: Yes No
After Care (Monday - Friday, 4:00pm - 6:00pm) $40/week: Yes No

CONTACT #1
First Name: Last Name:
Mailing Address: Home Phone:
Cell Phone: Work Phone:
E-mail:
Employer Name: Employer Phone:
Employer Notes:
CONTACT #2
First Name: Last Name:
Home Address: Home Phone:
Cell Phone: Work Phone:
E-mail:
Employer Name: Employer Phone:
Employer Notes:
EMERGENCY CONTACT (Not Contact #1 or #2)
First Name: Last Name:
Telephone #1: Telephone #2:
Comments:
I have read and agree to all Policies and Fees. A signed paper copy of this document must be submitted for each student, prior to your child's first day of class.