Student Full Name*        Age:*             Birthday: *        Male:     Female:

Address: * City: *   State:    Zip:

Parent/Guardian name:*

Home phone:*          Parent's work/cell phone: *          Email:*

Are there any medical conditions we should know about?:
*

What type of dance experience does the student have? *

How did you hear about us?*

Have you been referred to us by someone? Please let us know who:
*

We sometimes use candid shots for advertisements and promotions.
Do you give us permission to use images of your child for those purposes? * Yes No

In the box below, please list the classes that you are interested in taking:
*

*By checking this box I state that I have read and will abide by Studio Polices

Parent/Guardian Name:*       Date:*

* = required information