Registration Form
Dil Se Dance Company
Please fill out the form and click submit when finished.
Personal Information
Parent Name
First Name
Last Name
Student Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Gender
Please Select
Male
Female
Email Address
Phone Number
Please enter a valid phone number.
Current Residence Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list any vital information we may need to know such as of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
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Emergency Contact
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Relationship to Student
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Do you allow your child's photograph and video to be taken and used on social media platforms? Answer with Yes or No below.
Notes
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Type a question
Submit
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