440 Southlake Boulevard Suite 23C
Richmond, Virginia, 23236
Phone/ Fax 379-9393
www.allstardance.com
michelleallstardance@gmail.com
REGISTRATION 2010-2011
Please fill out completely.
Dancers’Name__________________________________________________________________________________
Name if different than first name____________________________________________________________________
Age (as of September)________________Date of Birth ________/______/__________ Home # ________________
Address__________________________________________City________________________Zip Code___________
Subdivision/Area___________________________________Upcoming School Grade_________________________
Previous Dance School___________________________________________________________________________
Previous Dance Instructor_________________________________________________________________________
Types of Dance Studied:Ballet______yrs. Tap_______yrs. Jazz_______yrs. Pointe______yrs. Lyrical_______yrs.
Any health problems_________________________Physical Limitations____________________________________
Medications/Allergies____________________________________________________________________________
How did you hear about us: Friend_______________ Advertising_______________Website___________ Other____
Guardian’s Name _____________________________________________Home #_______________
Work#______________________ Email ______________________________________
Cell Phone # (optional) _____________________________________
Emergency Contact __________________________Home #____________________________________________
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3rd Choice |
I agree to abide by the terms and conditions as stated in the payment schedule.
Signature____________________________________________________ Date_________________