| 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:
|
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:
|
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.
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