Student Registration Form

Dare to Dream Dance Center

471 Pompton Avenue, Cedar Grove, NJ, 07009

njdaretodreamdance@gmail.com

www.daretodreamdance.com

(973) 498-0009
Student Registration Form

(Complete ONE registration form for each student)
Date*

MonthDayYear
Date

Basic Information
Student Full Name*

First NameMiddle NameLast Name
Student Cell Number*
e.g. 11183021
Student Age
e.g. 11183021
Birth Date*

MonthDayYear
Present Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student Email*
Student Parent Name - Mother

First NameLast Name
Student Parent Phone Number - Mother
Please enter a valid phone number.
Student Parent Address - Mother

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Parent Name - Father

First NameLast Name
Student Parent Phone Number - Father
Please enter a valid phone number.
Student Parent Address - Father

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Relationship*
ex. Father, Mother, etc.
Emergency Contact Phone Number*
Please enter a valid phone number.
Is this a cellphone number that can receive emergency text?

YesNo
Emergency Contact Email*
example@example.com