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Touch of Class Dance Academy Registration
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Referral Information
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Additional Info
Emergency Contact Info (Not Contact #1 or #2)
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Contact #1
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Who is your employer?
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Employer Notes
Contact #2
Contact #2 First Name
Last Name
Type
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Mother
Parent
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Home Phone
Work #
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Email
(Emails are kept confidential)
Confirm Email
Who is your employer?
Employer
Employer Phone
Employer Notes
Student #1
Student's First Name
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Last Name
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Student Gender
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Birth Date
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Additional Info
Student Email
T-Shirt Size
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Adult Small
Adult X-Large
Child Large
Child Medium
Child Small
Child X-Large
Child X-Small
School
Grade Level
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
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college
college-freshman
college-sophomore
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Unknown value
Disabilities (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
Student #2
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Student's First Name
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Last Name
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Student Gender
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Male
Birth Date
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Additional Info
Student Email
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Child Large
Child Medium
Child Small
Child X-Large
Child X-Small
School
Grade Level
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
Student #3
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Student's First Name
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Last Name
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Student Gender
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Female
Male
Birth Date
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Additional Info
Student Email
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Child Large
Child Medium
Child Small
Child X-Large
Child X-Small
School
Grade Level
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
Student #4
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Student's First Name
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Last Name
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Student Gender
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Female
Male
Birth Date
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Additional Info
Student Email
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Child Large
Child Medium
Child Small
Child X-Large
Child X-Small
School
Grade Level
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
Student #5
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Student's First Name
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Last Name
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Student Gender
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Female
Male
Birth Date
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Additional Info
Student Email
T-Shirt Size
Adult Large
Adult Medium
Adult Small
Adult X-Large
Child Large
Child Medium
Child Small
Child X-Large
Child X-Small
School
Grade Level
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Primary Doctor
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December 22, 2024
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