Student Name
Address
City	State	Zip Code
Birthday	Age	Grade
Telephone #1	Telephone #2
Name of Parent/Guardian 1 Relation _____________________________	Name of Parent/Guardian 2 Relation _____________________________
Parent 1 Cell Phone	Parent 2 Cell Phone
Parent 1 Email	Parent 2 Email
Emergency Contact Name	Emergency Contact Phone

Class Registration

Class Day	Class Name	Class Time	Class Teacher

List any previous dance experience (please include style and how many years you participated).

Any health or physical restrictions with dancing?
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How did you hear about our studio?
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