| Tricia's Dance Extreme |
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Students Name:
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Address:
______________________________________________
City:
_______________
State:
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Zip Code:
________
Age:
____
Birthdate:
________
School:
______________
Grade:
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Number of years Training:
______
Please list any medical conditions we should be aware of:
__________________________________________________
Emergency Contact:
____________________
Phone:
_________________
Parent/Mother:
_____________________
Home phone:
___________________
Cell phone:
_____________________
Work phone:
____________________
Parent/Father:
_______________________
Home Phone:
____________________
Cell phone:
______________________
Work Phone:
_____________________
Classes: tap, jazz, hip-hop, modern, ballet, lyrical, special needs
Class Name:
______________________________
Private, Semi Private, Group:
_________________
½ hr or hour:
______________________
Competition group:
_________________________
Competition group is for everyone who would like to join.
please email this form to tricia@triciasdanceextreme.com
| Tricia's Dance Extreme 211 South St Lehighton Pa 18235 610-377-5500 |
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