REGISTRATION FORM

Student Name:

Address:

City:
State :
Zip:

Phone: Home:
Work:
Cell:

Email Address:

For Youth: Parents Name:

Birthday (MM/DD/YY):

For Adult: Birthday (MM/DD):

Emergency Contact Name:

Emergency Phone:

Classes:
Tap Workshops - please indicate date/classes below
SUMMER PLAYHOUSE - please indicate date below
Screenwriters Workshop with Tom Huckabee
Creative Movement
Intro to Dance
Art
Yoga
Zumba
Private Lessons

(exact time to be scheduled/ instructor)

Day/Time of Class(es):

Special Needs of the student: