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NAME
FIRST
MIDDLE INITIAL
LAST
MAILING ADDRESS
STREET/APT#
CITY
STATE
ZIP
TELEPHONE
EMERGENCY CONTACT
NAME
PHONE NUMBER
EMAIL ADDRESS
AGE & SCHOOL GRADE
(child / teen only)
SELECT ONE
5
6
7
8
9
10
11
12
13
14
15
16
17
ADULT (18+)
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KINDERGARTEN
1ST GRADE
2ND GRADE
3RD GRADE
4TH GRADE
5TH GRADE
6TH GRADE
7TH GRADE
8TH GRADE
9TH GRADE
10TH GRADE
11TH GRADE
12TH GRADE
Other
DANCE TRAINING & GOALS
YEARS OF TRAINING
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None
Less than 1 YR
1 - 4 YRS
5 - 9 YRS
10+ YRS
GOALS
Physical Limitations
DANCE CLASS SCHEDULE
( Select one or more classes attending )
Select
Date
Class
Time
Wks
Fee
6/15 - 7/27
Kids Hip Hop (ages 8-12)
5 p.m. -6 p.m.
7 wks
$63
6/15 - 7/27
Teen/Adult Hip Hop (ages 13 & Up)
6 p.m. – 7 p.m.
7 wks
$63
6/29 – 8/3
Teen Hip Hop (ages 13-17)
10:30 a.m. – 11:30 a.m.
6 wks
$54
6/29 – 8/3
Adult Hip Hop (ages 18 & Up)
9:30 a.m. – 10:30 a.m.
6 wks
$54
