DPDC Student Registration

Full Name

First NameLast Name

Date of Birth

MonthDayYear

Age

Grade

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

New or Returning Student?

Any health conditions?

If yes, please name

Desired Classes

Name

First NameLast Name

e-mail

Cell Phone

Area CodePhone Number

Relationship to Student

Name

First NameLast Name

Relationship to Student

Cell Phone

Area CodePhone Number

Drop off Program

I have read the above safety and drop off rules

By checking 'I Agree' below and submitting this form, you, the Parent or Guardian of the above student(s), agree to release Danielle Peyton Dance Company including instructors and assistants from liability for any and all injuries which may occur while training, practicing, performing, or during any studio event or activity.

You also agree that you are responsible for health and accident insurance and any medical costs incurred due to injury. You give permission for emergency medical transportation and treatment of your student(s) at your expense should the need arise.

You also give your permission for the public display of any studio visual images that your child may appear in.

please select

Today's Date

Date

Your spot will not be reserved until payment is submitted.

You can pay using venmo user id DPDANCE last four cell phone 0334

Dance Class Registration Form

Student Info

Parent/Guardian Info

Emergency Contact

Safety Procedures

Terms and Conditions

Payment