Registration

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Private, one-hour instruction with teacher upon request. Please let us know: 1. Teacher request 2. Day and time availability 3. Number of sessions registering for 4. Who you plan to take the class with *Registration is for the lesson - dates and time to be determined* 2 dancers/lesson

Event:

Start Date/Time:

End Date/Time:

Fee per Student:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Type*
	Home Phone:*	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Emergency Contact Info*

Students entered below will be added to your family's account

Add New Student #1:

(Show-Hide Details)

	Student's First Name: *	Last Name: *
	Student Gender: *	Birth Date: * (format=mm/dd/yyyy)
	Student Email:
	School:	Grade Level:
	Disabilities (Leave blank if NONE):
	Allergies (Leave blank if NONE):
	Medications (Leave blank if NONE):

Questions/Options:


Please select a teacher: (Ms. Avery, Mrs. Lynn, Mr. Antoine, Mrs. Krishna, Ms. Jordan)*
Please provide three options that you are available for during the week. *
How many lessons do you want to register for($30/Student/Hour/Session)?*
Who do you plan to take this class with?*

Additional Information: