Registration Form 2022-2023

Registration Form 2024-2025

Fill out the form carefully for registration
Student Name (1)*

First NameLast Name
Birth Date*

MonthDayYear
Student Name (2)

First NameLast Name
Birth Date

MonthDayYear
Student Name (3)

First NameLast Name
Birth Date

MonthDayYear
If there are any health concerns we should be aware of, please give details here.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail (if applicable)
example@example.com
Are you a new student at Leisa's?*

yesno
Do you have any dance experience other than at Leisa's? If yes, please indicate how many years in what discipline and any exam levels, if any, completed.
I am interested in (please check all that apply):

Ballet (6 years and over)Tap (5 years and over)Jazz (6 years and over)Hip Hop (7 years and over)Lyrical/Contemporary (9 years and over)Step DanceMajorette (baton twirling)Parent & Tot (ages 2-3)Pre Dance 1 (ages 3-4)Pre Dance 2 (ages 4-6)Adult Class (please indicate style choice in box below)Dance ConditioningZoom Classes
Please indicate your class time/day preference
Parent/Guardian (1) Name (if student is under 19)*

First NameLast Name
Parent/Guardian (1) Email*
example@example.com
Parent/Guardian (1) Cell Phone Number*
Please enter a valid phone number.
Parent/Guardian (1) Home Phone Number (if different from cell)
Please enter a valid phone number.
Parent/Guardian (1) Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian (2) Name

First NameLast Name
Parent/Guardian (2) Email
example@example.com
Parent/Guardian (2) Cell Phone Number
Please enter a valid phone number.
Parent/Guardian (2) Home Phone (if different from cell)
Please enter a valid phone number.
Parent/Guardian (2) Address (if different from Guardian 1)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize Leisa Whalen to use photographs taken of my child while attending Leisa's School of Dance to promote programs or be used in, or as part of publications, newsletters, advertisements, website and displays intended for the general public.*

YesNo
I, the undersigned, acknowledge that the participation in dance involves strenuous physical activity and that Leisa Whalen, Leisa's School of Dance, instructors and guest teachers will not be held responsible for injury of any kind as a result of participation.

Leisa's School of Dance cannot guarantee that myself or my child will not be exposed to (whether at Leisa's School of Dance or elsewhere), or if exposed, that myself or my child will not contract COVID-19.

By signing below, I agree to waive any claims of liability against Leisa's School of Dance and to hold Leisa's School of Dance harmless if I or my child contract COVID-19 despite their best efforts to prevent it.
Signature*

Clear
Once your form is submitted, you should immediately receive a Registration Received Thank you email. Please reveiw your information for accuracy. Leisa will contact you within 24 hours. Thank you!
Office Use Only:
Should be Empty:

Registration Form 2024-2025