Student Registration Form

Dare to Dream Dance Center

471 Pompton Avenue, Cedar Grove, NJ, 07009

njdaretodreamdance@gmail.com

www.daretodreamdance.com

(973) 489-0009
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

Other Details
Please check the box below if there are any specific learning or special needs that you think we should be aware of regarding the student. If you check this box, we will call you and discuss confidentially.*

YesNo
Please check the box to confirm you have read and agree to the Dare to Dream Dance Student/Parent Agreement Policy. This policy is also posted on our website at www.daretodreamdance.com.*

YesNo
Please check the box to confirm you have read and agree to the Dare to Dream Dance Student/Parent Tuition Policy. This policy is also posted on our website at www.daretodreamdance.com.*

YesNo
Who/what is the name of your sponsor?
Thank you for your registration. Our staff will call or email you with final confirmation of your dance class schedules. Please give us at least two weeks to confirm.

Feel free to email us at njdaretodreamdance@gmail.com if you do not hear from us within the indicated timeframe.
To What Course?
Please verify that you are human*
Should be Empty: