Student Name:*

Age: Birthday: Male: Female:

Address: City: State: Zip:

Parent/Guardian name:

Home phone: Parent's work/cell phone:

Email:*

Any medical conditions we should know about?:

What type of dance experience does the student have?

How did you hear about us?

Have you been referred to us by someone? Please let us know who:

We sometimes use candid shots for advertisements and promotions.
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In the box below, please list the classes that you are interested in taking:

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Parent/Guardian Name:* Date:

* = required information