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Need a little break from the busy life of parenting/care-taking? Bring your kiddo(s) ages 3 and up to the Wellspring Dance Academy and get a little down time! We have a full evening of activities planned including movement activities like obstacle courses and creative movement-style explorations, crafts, snacks, and more. We will keep them busy while you do whatever it is you want/need! Be sure to tell your friends too!
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Name
First Name:
*
Last Name:
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Type
Caregiver
Father
Guardian
Mother
Other
Parent
Self
Teacher/Choreographer
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
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State:
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
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GA
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IA
ID
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OR
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Zip:
*
Emergency Contact Info (Not Contact #1 or #2)
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:
*
Gender Identity:
Female
Male
Non-Binary
Prefer to not disclose
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Race/Ethnicity (for grant reporting purposes):
:
*
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Gender Identity:
Female
Male
Non-Binary
Prefer to not disclose
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Race/Ethnicity (for grant reporting purposes):
:
*
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Gender Identity:
Female
Male
Non-Binary
Prefer to not disclose
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Race/Ethnicity (for grant reporting purposes):
:
*
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Gender Identity:
Female
Male
Non-Binary
Prefer to not disclose
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Race/Ethnicity (for grant reporting purposes):
:
*
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Gender Identity:
Female
Male
Non-Binary
Prefer to not disclose
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
Race/Ethnicity (for grant reporting purposes):
:
*
Questions/Options:
Does your child(ren) have any medical concerns that we should be aware of? Please describe.
Does your child(ren) have any dietary restrictions we should be aware of? Please describe.
How did you find out about this event?
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number:
Visa
Mastercard
Name as it appears on card:
Nickname:
Card Expiration Month:
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Exp Year:
2024
2025
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Address Line 1:
Address Line 2:
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
PR
VI
Zip:
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