Registration
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Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Caregiver
Father
Guardian
Mother
Parent
Self
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
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
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
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:
*
Female
Male
Non Binary
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Non Binary
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Questions/Options:
Dancer's Name
*
Type of Dance Gram (3-line: $5, Business Card: $15, Half Page Ad: $55, Full Page Ad: $105)
*
Text of Dance Gram. For Half and Full Page Ad, please email pictures/text to jdo5678@comcast.net.
*
Additional Information:
Other Questions/Comments:
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