ADDRESS  

CITY STATE ZIPCODE  

BIRTHDATE           AGE (as of September)  

HOME PHONE NUMBER   EMAIL  

CELL PHONE : MOTHER   FATHER  

MOTHER’S NAME WORK PH. 

FATHER’S NAME WORK PH. 

PLEASE CHECK CLASS(ES) OF INTEREST: 

BALLET   JAZZ   TAP   MODERN   LYRICAL   IRISH STEP 

TAP/BALLET/ACRO   ADULT CLASSES   MOMMY & ME 

PLEASE LIST ANY PREVIOUS DANCE EXPERIENCE:

HOW DID YOU HEAR ABOUT US? 

YELLOW PAGES 

NEWSPAPER 

MAILER 

REFERRAL   - Name of person who referred the studio 

PERFORMANCE     WHERE?

 NAME (last)           (first) 

ADDRESS  

CITY STATE ZIPCODE  

BIRTHDATE           AGE (as of September)  

HOME PHONE NUMBER   EMAIL  

CELL PHONE : MOTHER   FATHER  

MOTHER’S NAME WORK PH. 

FATHER’S NAME WORK PH. 

PLEASE LIST DAY, CLASS AND INSTRUCTOR FROM 2005/2006DANCE YEAR 

DAY CLASSTIME INSTRUCTOR 

DAY CLASSTIME INSTRUCTOR 

DAY CLASSTIME INSTRUCTOR 

DAY CLASSTIME INSTRUCTOR 
 

PLEASE CHECK CLASS(ES) OF INTEREST FOR 2005/06 DANCE YEAR: 

BALLET   JAZZ   TAP   MODERN   LYRICAL  

TAP/BALLET/ACRO   IRISH STEP (10 yrs. & UP)   ADULT JAZZ

PLEASE LIST DAY & TIME PREFRENCE: 

1ST 
2ND
3RD  

CARPOOLS WITH: 

** WE CANNOT GUARANTEE TO ACCOMMODATE EVERYONE WITH THEIR PREFERRED DAY & TIME DUE TO TEACHER AND ROOM AVAILABILITY.  WE WILL DO OUR BEST—THANK YOU IN ADVANCE FOR YOUR UNDERSTANDING** 

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