Online Dance Class Registration Form

Name*

First NameLast Name

Age*

Date of Birth*

Date

Gender Identity*

What are your pronouns?*

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have any disabilities or physical or learning needs that we should be aware of? Please let us know how we can accommodate your body and needs.

Why are you coming for dance and movement classes? What would you like us to know about you?

Do you have any song or artist requests?

Are there any classes we are not offering yet that you would like us to offer? Are there specific days and times that we are not offering that you want us to offer?

Are you interested in teaching modern/contemporary, ballet, or gentle movement and/or would like to teach other dance/movement classes not yet offered? We will eventually have a few teachers on rotation for these classes and will expand what we are offering. If so, please list your experience and send a separate email to sara@cyclicalpamc.com with your resume and letter of interest.

Are you interested in performing in dance/theatre performances and/or collaborating with choreography or other aspects of performance and production? Cyclical Psychotherapy and Movement Collective is also home to =ibrium Dance Project: Dance for EveryBODY, a dance/theatre performance company. If so, please list your general experience and send a separate email to sara@cyclicalpamc.com for more information on upcoming projects and auditions.

What Class(es) are you signing up for (you must sign up no less than 2 hours before the class starts)?*

Monday 1/12 at 7:15-8:45pm: 18+ Dance with a Drag QueenTuesday 1/13 7:15-8:45pm: Teen/Adult Modern/Contemporary DanceWednesday 1/14 7:15-8:45pm: Teen/Adult Gentle MovementSunday 1/18 1:30pm-3pm: Teen/Adult Gentle MovementTuesday 1/20 at 7:15-8:45pm: 18+ Dance with a Drag QueenWednesday 1/21 at 7:15-8:45pm: Teen/Adult Ballet

Parent/Guardian Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Relationship

Class Rates

$25 per class
$80 for a 4 class pass (must be used with 1 year of purchase, void after 1 year)
Sliding Scale: if you cannot afford the $25 fee, please pay what you can from $5-$20 per class

Payment Method*

Cash (payment in person)PayPalVenmo

You can make a payment from our website, or pay in person with cash. If you have difficulty paying online, the instructor will have a QR code you can scan to pay with paypal or venmo. Regardless of how you pay, you agree to make all payments except for cash payments or if you are having difficulties making the online payment, a minimum of 2 hours before the class and payments must be received before the class begins.

By signing and submitting this form, I acknowledge that I am willfully attending dance and movement classes at Cyclical Psychotherapy and Movement Collective. I understand that there are always physical risks with any dance or movement class and that it is my responsibility to make safe choices for my own body in class. I acknowledge that Cyclical Psychotherapy and it's instructors are not legally liable if I have an injury in class or practicing class material outside of the classroom.

I understand that Cyclical Psychotherapy and Movement Collective is inclusive of all folx identifying as LGBTQ+, BIPOC, persons with disabilities, neurodiverse, and all body sizes. I understand this organization is built on equity and inclusivity. I understand that it is meant to be a safe space for all people and that any hate or discrimination is not tolerated. I promise to treat all individuals with respect and dignity. I understand that if I engage in any disrespectful or hateful behavior (at the discretion of Cyclical Psychotherapy and its instructors), agressions or microagressions against others, without any repair, I will be asked to leave and I will not receive any refunds.

Signature of Student*

Date Signed*

Date

Parent/guardian Name

First NameLast Name

Parent/guardian Signature

Date Signed

Date

Online Dance Class Registration Form

Student Information

A Few Things About You

Parent/Guardian Information

Payment & Confirmation

Liability Release

Parent/Guardian Permission (only for minors)