Adaptive Dance Class Registration

Student Name*

First NameLast Name

Age*

Date of Birth*

Date

Parent/Guardian Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Where you referred to this class by anyone? Please share their name.

Select the option that applies. All support people are expected to fully participate in the class.*

I (Parent/Guardian) or a support person of my choosing will participate in the class with my child.I would like a staff member/volunteer to be designated to participate with my child.

Will you need supervision for other children in your care during the class?

YesNo

Please use this space to give us any information you would like us to know about your child and his/her needs. Any special accommodation requests?

How does your child communicate their needs?*

Does your child have experience participating in a school/group class?*

YesNo

Please describe what worked or did not work in that environment.

Does your child have any sensory sensitivities or needs?*

YesNo

Please select your child's sensory sensitivities

Auditory (loud music or noises)Tactile (surface textures)Visual (bright lights/colors or flashing lights)Other

Please explain what other sensory needs your child may have.

Thank you for your interest in Adaptive Dance at Northern Plains Dance. Because your child is under 4 years old, they are not eligible for the current offerings. We suggest that you consider Dance Together as an option until they are old enough to participate in Adaptive Dance. Please submit this form to be added to the mailing list for future Sensory Friendly classes and performances through Northern Plains Dance.

Select your class sessions.*

Session 3 | January 10 - February 75 Week Session | Fridays 5:45pm-6:15pm

$47.00

Session 4 | February 21 - March 215 Week Session | Fridays 5:45pm-6:15pm

$47.00

Session 5 | April 4 - May 95 Week Session | Fridays 5:45pm-6:15pm (no class session on Good Friday)

$47.00

Enter coupon

Total

$0.00

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By signing below, you release Northern Plains Dance and its agents and employees from all liabilty for personal injury, illness or property damage occurring on or off premises used, rented, leased or owned by NPD. Northern Plains Dance reserves the right to take photographs and/or videos during class. These may include participants. Photos and videos may be used for promotional purposes, including online.

Signature*