Tricia's Dance Extreme
 |  |  |  |  |  |
Extreme Summer Program Registration
| Tricia's Dance Extreme 211 South St Lehighton Pa,18235 610-377-5500 |
Students Name:_____________________________________
Address:___________________________________________
City____________ State____ Zip____________
Age ___________
Birthdate:____________
School:_______________
Grade:________
Number of years training:________
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___-____-_____
Tuesday
____ 9:30am-11:00am Students 9 years old and up
~*~ Tuition $50
____ 11:00am-12:00pm Students 4 years old-8 years old
~*~ Tuition $35
Wednesday
____4:00pm-5:00pm Students 4 years old-8 Years old
~*~ Tuition $35
____ 5:00pm-6:30pm Students 9 Years old and up
~*~ Tuition $50
Address:___________________________________________
City____________ State____ Zip____________
Age ___________
Birthdate:____________
School:_______________
Grade:________
Number of years training:________
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___-____-_____
Tuesday
____ 9:30am-11:00am Students 9 years old and up
~*~ Tuition $50
____ 11:00am-12:00pm Students 4 years old-8 years old
~*~ Tuition $35
Wednesday
____4:00pm-5:00pm Students 4 years old-8 Years old
~*~ Tuition $35
____ 5:00pm-6:30pm Students 9 Years old and up
~*~ Tuition $50