AFTER SCHOOL PROGRAM

1
Student's Full Name* This field is required.
First Name
Last Name
2
Student's/Parent's E-mail* This field is required.Use your best email address please
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Current School's Name* This field is required.Type the name of the the student's school
5
Grade Level* This field is required.We pick up your child from his or her school
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
6
Does the student has any mental or physical disabilities?
YESNO
7
Please list any mental and/or physical disabilities, if any.* This field is required.If none, type N/A
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Normal
Small
Ok
Ok
8
Does the student have any allergies?* This field is required.
YESNO
9
Is the student on any medication?* This field is required.
YESNO
10
Please provide instructions for all medication that the student needs to take while with us.* This field is required.If none, type N/A
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Small
Ok
Ok
11
Guidance Counselor's Name
12
Mother's Name* This field is required.
13
Mother's Email* This field is required.
14
Mother's Cell Phone #* This field is required.
15
Father's Name
16
Father's Email
17
Father's Cell Phone #* This field is required.
18
Is the student a current student of Davis Dance Room?* This field is required.
Yes
No
19
What is the pick up time for the student?* This field is required.We pick up your child from his or her school. We need to kn.ow the time that we should pick him or her up
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Normal
Small
Ok
Ok
20
Do you play on a school sports team? If so, which ones?* This field is required.
21
Do you have a computer at home?
Yes
No
22
This program comes with FREE dance classes during the program hours. Do you have any disabilities preventing you from participate?* This field is required.
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Ok
Ok
23
Please upload a picture of the student.Not required but prefered
Drag and drop files here
Select files to upload
Max. file size: 1.0MB
Upload a File
Cancelof
24
By submitting this application you certify and warrant that the information provided is true and correct to the best of your ability. You further certify and warrant that you understand the fact that Davis Dance Room dba DDR and/or program administrator has the right to accept and/or deny your application for any reason or no reason at all. Please read DDR's terms and conditions. The program's term and conditions will be provided at orientation/parent's meeting. We will contact you for payment but if you have any questions, please call (863)307-6811.Please contact program Director for more information
25
Please verify that you are human* This field is required.
Should be Empty: