Student Name:
Parent/Guardian Name:
Address (Include City, State, Zip):
Home Phone Number:
Cell Phone Number:
Email Address:
Student Birth Date:
Student Current Age:
School/Grade:
Previous Dance Experience? If YES, where?
This is my ______ year of dance: 5th
10th
15th
other
Emergency Contact Information (Please include phone number, address, relation to student) :
Allergies:
Recital T-Shirt Size (keep in mind dancers will be wearing this in June- you will be billed at a later date ) Child Extra Small 2-4
Child Small 4-6
Child Medium 10-12
Child Large 12-14
Adult Small
Adult Medium
Adult Large
Adult X-Large
Credit Card Type: (This year we will be holding a credit card on file. Please note: Credit Cards will ONLY be charged if you have an outstanding balance one week before the recital). All regular payments will need to be paid in CASH or CHECK:
Credit Card Number:
Expiration Date:
Security Code:
Name on Card and Billing Address:
Which Classes are you registering for? Please include CLASS NAME, DAY, & TIME (See "Tentative Schedule Tab" for days and times):
How did you hear about us? (If by a student already enrolled please tell us who):
Questions or Comments?

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