New Student Child — Creative Dance Center

NEW STUDENT (CHILD)

Name

First Name

Last Name

Birthday

Home Address

Allergies/Medical Restrictions

Primary Contact

First Name

Last Name

Relationship to Student

Primary Contact Phone

(###)

###

####

Email

Secondary Contact

First Name

Last Name

Relationship to Student

Secondary Contact Phone

(###)

###

####

Which class(es) are you interested in signing up for?