Workshops Registration

Child Information

Child's Name

Gender Male Female
Parent/Gaurdian's Name
Address
,   
Email

Date of Birth

Month/Day/Year Age as of September 2011
Years of Training Ballet Jazz Tap  
Phone Home
Cell
Work Other

Ages

Workshop

Length

Dates

Time

Cost

 

6-8
Breakin 4 weeks Jan 5-26, 2014 2:00-3:30 pm $140
Theater Dance 4 weeks Mar 2-23, 2014 2:00-3:30 pm $140
Hip-Hop 4 weeks Apr 27-May 18, 2014 2:00-3:30 pm $140
9-12
Breakin 4 weeks Jan 5-26, 2014 3:00-4:30 pm $140
Theater Dance 4 weeks Mar 2-23, 2014 3:00-4:30 pm $140
Hip-Hop 4 weeks Apr 27-May 18, 2014 3:00-4:30 pm $140

 

Emergency Contact Information

Name

Phone

Relationship

Please list any allergies, chronic illness or other medical conditions which teachers and medical personnel should be aware of:

Child's Primary Physician
Phone

Program:
Please call 212-582-9304 ext 25 or 26 to be placed on the waiting list for any class marked FULL. No refunds up to 2 weeks prior to start date of each workshop. If a refund is issued, a $25 admin fee will be withheld


By submitting this form, you will be registered for the Workshop(s). Your registration will not be completed until Payment is recieved.