Registration Form
Student Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent or guardian information if under 18y
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
*
Please Select
Social media
Family
Other
Select classes
*
6:00p - 7:00p classical ballet
7:00p - 7:30p tap
7:30p - 8:00p jazz
I understand by my child and/ or myself participating in classes at 111 Cotton Street, West Monroe, LA, that the instructor(s) and/or the owner are not responsible or liable for personal injury and/or accidents which may occur as a result of participating in this program or by being on this property. I, hereby, give my consent for the instructor(s), after reasonable attempts to contact me have been unsuccessful, to seek medical help or initiate first aid for my child, if necessary.
*
I agree
Signature
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