DANCER
INFORMATION

Name*

Birth Date*

Grade he/she will start in the Fall 2011*

School Registered to Attend for 2011-2012*

Gender
 Female Male

HOUSEHOLD
INFORMATION

Parents Names*

Primary Phone Number*

Primary Email Address*

Street Address*

City*

Zip Code*

ALTERNATE
CONTACT
INFORMATION

Mother

Mobile Phone

Work Phone

Employer

Email

Father

Mobile Phone

Work Phone

Employer

Email

If living part time with other parent/family member, please provide following:

ADDITIONAL
INFORMATION

Student Health Status: Please discuss any special conditions, medications, aches/pains, handicaps, allergies, etc., that we should be aware of:

Name of Doctor

Doctor Phone Number

Insurance Carrier

Insurance Carrier Policy Number:

Emergency Contact (If Parent(s) Not Available)*

Emergency Contact Number*

FINAL
INFORMATION

Where Did You Hear About Dance Tech?

Receive class info via e-mail including performance times, notes to parents, etc.
 Mother Father

Class(es) This Dancer is Registering For (Class, Weekday(s) and Time)*