2023-24 Registration form Student's Name * First Name Last Name Student's Date of Birth * MM DD YYYY Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian * (if 18 years of age or older, write N/A) First Name Last Name Email Address * Phone # * (###) ### #### Emergency Contact #1 * First Name Last Name Phone * (###) ### #### Emergency Contact #2 First Name Last Name Phone (###) ### #### Please list any current medications. Please list any medication allergies. Please list any food allergies. Please list any other allergies. Please list any chronic health concerns. Please inform us of any other vital information you think we may need to know in the event of an emergency. Class Selection * Select all that apply Schedule can be found under "Classes" House Waacking Ballet Femme Hip Hop Hip Hop Choreo Popping Locking I Know I Can Hip Hop History & Culture I will pay with: * Cash Credit Card Check Thank you for registering for our program!
