Very Small Planet Dancers
Registration
STUDENT INFORMATION (please print)
Student's Name: _________________________________Nickname:_______________
Student's Address: _______________________________________________________
City_________________________
State___________ Zip ___________
Gender: ________ Age:
________ DOB:
______________
Grade:
Medical Conditions:
______________________________________________________
Previous dance experience (include
years and type of dance):______________________
_______________________________________________________________________
PARENT INFORMATION (please print)
Mother’s Name:
__________________________________________________________
Mother’s phone number: ______________________ Cell Number: __________________
Father’s Name:
___________________________________________________________
Father’s phone number: _______________________ Cell Number:
__________________
Other Responsible Person: __________________________________________________
Relationship to Student:
____________________________________________________
Phone Number: _____________________________ Cell Number: __________________
Email Address for Reminders: _______________________________________________
EMERGENCY CONTACTS
Name: ____________________________________ Phone Number: _____________
Name: ____________________________________ Phone
Number: _____________
____ Yes, my child’s picture can
be used on the Small Planet Dancers' website and related published material.
____ No, my child's picture
cannot be used on the Small Planet Dancers' website and related published material.
___________________________________ ___________________________
parent signature date