Must Circle One: Family (more than 1 student) Non-Family

Student's Last Name ___________________________________________

Student's First Name & M.I. ___________________________________

Address _______________________________________________________

City _________________________ , Ky Zip Code ___________________

Home Phone _______________________________ Year ________________

Birthday ______________ Grade _______ School ___________________

Parent/Guardian's Name __________________________________________

Email Address ___________________________________________________

Tuition (office use) ________________ Codes (office use) ________

Mother's Work Phone _____________________________________________

Father's Work Phone _____________________________________________

Class Day & Time Preferred ______________________________________

circle if interested: PRE-ACCEL ACCEL PRIVATE

COMPETITION (LEVEL)__________ DUO/TRIOS

________________________________________________________

NEW STUDENTS ONLY:

PREVIOUS DANCE TRAINING _______________________________

_________________________________ DURATION ____________

circle how you heard about our studio: YELLOW PAGES

FAMILY    ALUMNI    TELEVISION    RADIO      NEWSPAPER