Registration Form 2021-2022

Family Information
Last Name: *
BOTH Parent's Names: *
The Address field is REQUIRED. If you do not have any information to enter into "Street Address Line 2", please enter NA or Not Applicable. If you do not put text in that field the form submission will FAIL
Address *

Street Address

Street Address 2 (Apt, Number, etc.). If not applicable put NA or Not Applicable

City State / Province

Postal / Zip Code Country
Is this a new address? Select one *

Yes No
Cell Phone Number: *
Home Phone Number: *
Place of Employment
Father:
Work Phone Number:
Mother
Work Phone Number:
Email Address:
Names and Ages of Other Children
Emergency Contact (not living at same address)
Emergency Name *
Emergency Phone Number *
Referred By *

News Ad Yellow Pages Friend* Sign Other
If you answered "Friend" who can we thank for referring you?

Student Information (First Student)
Student # *
Last Name: *
First Name and MI: *
Same address as above? *

Yes No*
*If different address than entered into address under Family Information, please enter student's address below
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number:
Birth Date *

Month Day Year
Gender *

Male Female
Age *
Grade *
Any health condition we should be aware of? *

Yes No
If Yes, please provide more information
Dance Experience and Teachers (other than OCD)
If Registering more than ONE student, please complete the additional Student Information Section below. If Registering ONLY one student, please continue to the Dance Registration Section

Student Information (Second Student)
Student #
Last Name:
First Name and MI:
Same address as above?

Yes No*
*If different address than entered into address under Family Information, please enter student's address below
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number:
Birth Date

Month Day Year
Gender

Male Female
Age
Grade
Any health condition we should be aware of?

Yes No
If Yes, please provide more information
Dance Experience and Teachers (other than OCD)
If Registering more than TWO students, please complete the additional Student Information Section below. If Registering ONLY two students, please continue to the Dance Registration Section

Student Information (Third Student)
Last Name:
First Name and MI:
Same address as above?

Yes No*
*If different address than entered into address under Family Information, please enter student's address below
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number:
Birth Date

Month Day Year
Gender

Male Female
Grade
Age
Any health condition we should be aware of?

Yes No
If Yes, please provide more information
Dance Experience and Teachers (other than OCD)

Signature
I give permission for the student(s) named above to receive instruction at Oxford Center for Dance, Inc. I give permission for any photos and/or videos taken of my child/children named above to be published in any Oxford Center for Dance, Inc. advertising, promotions, websites, yearbooks, etc. I have received a copy of the rules and regulations. I have read and agree to abide by all of them. I release and discharge the sponsoring organization, Oxford Center for Dance, Inc., it’s agents, servants, and employees from any and all claims for personal injuries or property damage sustained by the student(s) named above while in or around the present studio location as well as during off premises activities such as, but not limited to yearly competitions, meets, conventions and seminars.
Select One *

I agree I do not agree
Electronic Signature (type name) *
**COMPLETELY FILL OUT ALL PERTINENT INFORMATION ON THIS FORM**

****INCOMPLETE FORMS WILL CAUSE DELAY IN REGISTRATION****

Enter information below to register for dance classes

OXFORD CENTER FOR DANCE, INC.