3s Parent-child Dance archive 2016-17

Parent/Guardian First Name: *

Parent/Guardian Last Name: *

Parent/Guardian Email: *

Phone: *

Street Address: *

City: *

State: * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip: *

Student First Name: *

Student Last Name: *

DOB: *

Name of school, if applicable:

New or Returning Student?: * New Returning

Previous Dance Experience: None 1yr 2yr 3yr 4yr 5yr+

Dance Experience Notes? (ie, What kind of Dance?):

Emergency Contact #1 Name & Phone #: *

Emergency Contact #2 Name & Phone #: *

Authorized party for pick-up: *

Physician Name & Phone #: *

Does your child have any special needs to ensure his/her success in our class?:

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