2025-2026 Dance Classes Registration

Groovy Glides Dance Academy 2025-2026 Registration Form

Where passion meets movement
Dancer's Full Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dancer's Age
Dancer's Grade
Parent/Guardian Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Relationship to Dancer
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How many years of previous dance experience?
Medical Conditions or Allergies
How did you hear about us?

Other
Terms and Conditions:

I understand, being the parent or legal guardian of the listed child do hereby agree to hold Keiro’Deza Johnson and her instructors free and harmless from any injury claim which the named child may incur as a result of taking dance steps taught. I understand that I am responsible to pay my account by the first dance class of each month from August to April and that all fees are nonrefundable. I also agree and am responsible to pay all fees charged until the recital, including but not limited to tuition each month. By agreeing to the Terms and Conditions of this Registration, I give permission to Groovy Glides Dance Academy to take and post pictures of my child to their social media platforms, Facebook and Instagram.
Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

My Products

Early Bird Registration Fee

The registration fee must be paid at the time of form submission. Please note that all registration fees are non-refundable

$45.00

Total

Credit Card

Should be Empty:

Groovy Glides Dance Academy 2025-2026 Registration Form

My Products*

Credit Card

My Products