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Kelly Academy of Irish Dance
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Referral Information
How did you hear about us?
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Family Information
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Primary Phone
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Additional Info
Emergency Contact Info (Not Contact #1 or #2)
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Contact #1
Contact #1 First Name
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Last Name
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Type
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Caregiver
Father
Guardian
Mother
Parent
Self
How Can We Contact You?
Work #
Cell #
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Portal Access (your email is your login)
Email
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(Emails are kept confidential)
Confirm Email
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Portal Account Password
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Contact #2
Contact #2 First Name
Last Name
Type
Caregiver
Father
Guardian
Mother
Parent
Self
How can we contact you?
Home Phone
Work #
Cell #
Email
(Emails are kept confidential)
Confirm Email
Student #1
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
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Adult Large
Adult Medium
Adult Small
Adult X-Large
Youth Large
Youth Medium
Youth Small
Youth X-Large
Youth X-Small
School
*
Grade Level
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Shoe Size
*
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Prior Irish Dance Experience
*
Previous School Name
Student #2
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Additional Info
Student Email
T-Shirt Size
*
Adult Large
Adult Medium
Adult Small
Adult X-Large
Youth Large
Youth Medium
Youth Small
Youth X-Large
Youth X-Small
School
*
Grade Level
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Shoe Size
*
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Prior Irish Dance Experience
*
Previous School Name
Student #3
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Additional Info
Student Email
T-Shirt Size
*
Adult Large
Adult Medium
Adult Small
Adult X-Large
Youth Large
Youth Medium
Youth Small
Youth X-Large
Youth X-Small
School
*
Grade Level
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Shoe Size
*
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Prior Irish Dance Experience
*
Previous School Name
Student #4
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Additional Info
Student Email
T-Shirt Size
*
Adult Large
Adult Medium
Adult Small
Adult X-Large
Youth Large
Youth Medium
Youth Small
Youth X-Large
Youth X-Small
School
*
Grade Level
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Shoe Size
*
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Prior Irish Dance Experience
*
Previous School Name
Student #5
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Additional Info
Student Email
T-Shirt Size
*
Adult Large
Adult Medium
Adult Small
Adult X-Large
Youth Large
Youth Medium
Youth Small
Youth X-Large
Youth X-Small
School
*
Grade Level
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Shoe Size
*
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
Prior Irish Dance Experience
*
Previous School Name
Add Another Student
Required Policies
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I Agree to All of the Above
Enter your Full Name
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November 11, 2024
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MT
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NE
NH
NJ
NM
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OH
OK
OR
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RI
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