Student Info
Student Name
*
First Name
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Student Email
example@example.com
Parent/Guardian and Adult Student Info
Parent/Guardian or Adult Student Name
*
First Name
Last Name
Parent/Guardian or Adult Student Email
*
Confirmation Email
example@example.com
Cell Phone Number
*
Secondary Phone Number
Address
*
Street Address
Street Address Line 2
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Postal Code
Student Medical and Emergency Info
Student Care Card Number
*
Student Allergies/Medical Issues
Emergency Contact
*
Class Selection
Student Age Range
*
1.5-3
3-4
5-7
7-9
10-11
12-14
15-17
Adult Beginner (18+ with limited dance experience)
Adult Advanced (18+ with lots of dance experience)
Preferred Location
*
Kelowna - 331 Banks Road
West Kelowna - 17-1515 Westgate Road
Either/Both locations
Kelowna Class Selection Ages 1.5-3
*
Kelowna Class Selection Ages 3-4
*
West Kelowna Class Selection Ages 3-4
*
West Kelowna Class Selection Ages 1.5-3
Kelowna Class Selection Ages 5-7
*
West Kelowna Class Selection Ages 5-7
*
West Kelowna Class Selection Ages 7-9
*
Kelowna Class Selection Ages 7-9
*
Kelowna Class Selection Ages 10-11
*
West Kelowna Class Selection Ages 10-11
*
Kelowna Class Selection Ages 12-14
*
West Kelowna Class Selection Ages 12-14
*
Kelowna Class Selection Ages 15-17
*
West Kelowna Class Selection Ages 15-17
*
Kelowna Class Selection Adult
*
West Kelowna Class Selection Adult Beginner
West Kelowna Class Selection Adult Advanced
Permissions & Release
I authorize Dance Inertia School of Dance to use the likeness of the above student in all forms of media for advertising purposes.
*
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