Registration
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Looking to keep up your dance skills over the summer? Want some practice in learning choreography quickly for upcoming auditions? Just want to move and have some fun? This class is for you!
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
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Family Information
First Name:
*
Last Name:
*
Type
*
Caregiver
Father
Guardian
Mother
Parent
Self
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
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City:
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State:
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Zip:
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Students entered below will be added to your family's account
Add New Student #1:
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Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #2:
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Student's First Name:
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Last Name:
*
Birth Date:
*
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Allergies (Leave blank if NONE):
Add New Student #3:
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Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #4:
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Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #5:
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Student's First Name:
*
Last Name:
*
Birth Date:
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Allergies (Leave blank if NONE):
Questions/Options:
Please give brief description of student's performance experience (school, community, church, etc.)
*
Please share any information about the student that will be helpful for the teacher to know (special needs, diagnoses, allergies, etc.)
Additional Information:
Photo Consent
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I give photo and video consent to Kelly's Music Corner, LLC. for student's likeness to potentially be used on social media and for marketing purposes.
I've read the above and agree.
Payment
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I understand payment must be made at the time of registration.
I've read the above and agree.
Payment Conditions
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I understand my payment is non-refundable. Should student be unable to attend the workshop, the payment will be held as credit towards a future KMC class/lessons/etc.
I've read the above and agree.
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Other Questions/Comments:
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eCheck/Bank Draft:
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Bank Routing Number:
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Your Account Name:
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Your Account Type:
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