Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
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
Dancer's first name*
Will your dancer be in person or virtual*
Age of dancer as of 1/2/2020*
During each session, we will be splitting the group into 2 smaller groups. Is there a family member or friend your dancer wants to be in a group with? If so, please list the name of the family/friend*
How did you hear about us?*
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number: *  
Name as it appears on card: *
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*