Dancer Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Other

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

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Styles of Dance I Am Interested In Taking:

HIP HOP

JAZZ

BALLET

BREAKIN'

TAP

POPPIN' / FUNK

CIRQUE/ACRO

CONTEMPORARY

DANCEHALL

How did you hear about us? *

Social Media

Word of Mouth

School Program

Online (Google)

Word of Mouth

Friend

Live Performance

Other

Goals of dance *

Fun

Fitness

Confidence/Social

Performance

Professional

Competition

Other

Emergency Contact *

(Other than the guardian)

First Name

Last Name

Phone *

Emergency Contact #

(###)

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