Info & Forms > Registration Form - 2010 - 2011

Please fill out this application and then press the submit button to print it off.

Parent/Guardian #1: Parent/Guradian #2:
Home Address: Zip Code:
Home Phone:
XXX-XXX-XXXX		 Cell Phone:
XXX-XXX-XXXX
Work Phone:
XXX-XXX-XXXX		 Parent Email:
       
1- Dancer's Name: 1- DOB:
MM/DD/YYYY
    1- Email:
2- Dancer's Name: 2- DOB:
MM/DD/YYYY
    2- Email:
3- Dancer's Name: 3- DOB:
MM/DD/YYYY
    3- Email:
       
Ins Provider: Policy #:
Sub/Group #:    
Allergy(s)/Medical Conditions:
       
Emergency Contact (Other than parent)    
Name: Relation:
Contact #:
XXX-XXX-XXXX		    
I authorize the following adult to pick-up if I am unable to:    
Name: Relation:
Contact #:
XXX-XXX-XXXX		    
       
How did you hear about us?
   

Once you are done filling out the form press Submit.