Dance Class Student Information

Participant's Name *

First Name Last Name

Age *

Parent's Name *

First Name Last Name

Parent's Phone Number *

- Area Code Phone Number

Parent's E-mail Address *

Emergency Contact Name *

First Name Last Name

Emergency Contact Phone Number *

- Area Code Phone Number

In order for us to get to know your child, please answer the following questions:

Does your child have previous dance experience?

Does your child exhibit sensitivity to touch? *

Yes No

Please explain.

Does your child exhibit sensitivity to sounds? *

Yes No

Please explain.

Does your child exhibit non-compliant behaviors requiring more assistance other than redirection? *

Yes No

Please explain.

Are there any medical issues we need to be aware of? *

Please check all that apply

Eye Contact *

Maintains eye contact Occasionally makes eye contact with the other person Glances in the direction of the other person but does not make direct eye contact Avoids eye contact Stares at the floor

Communication *

Communicates using complete sentences Communicates using single words Communicates using signs and gestures Does not communicate verbally or with signs and gestures

Willingness to participate during structured activities *

Responds to adult instruction Participates with minimal prompting or redirection Warms up to new activities Very often refuses to participate in structured activities

Is there anything else you would like us to know about your child?

Please attach a picture of the participant

*DSALA wishes to provide a pleasant experience for all participants. Therefore, a parent or guardian must be present for the duration of each class to ensure that each participant is following class rules.

2018 Class Schedule:
Saturday, March 17, 2018
Saturday, April 21, 2018
Saturday, May 19, 2018
Saturday, June 16, 2018
Saturday, July 21, 2018
Saturday, August 18, 2018
Saturday, September 15, 2018
Saturday, October 20, 2018

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