Adult Registration 2020-2021 Adult Dance Registration Form InformationName* Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Emergency Phone*Permission Emergency/Medical TreatmentIn case of an emergency requiring medical treatment, I/we give permission to receive such treatment services as are deemed in my best interest at the time of the emergency. I/we accept financial responsibility for those services. If possible, I/we will be contacted prior to initiating treatment.Known Allergies*Doctors Name*Doctors Phone #*Preferred Hospital*Hospital Phone #*Hospital Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Choose Dance Classes* Adult Hip-Hop Adult Floor Barre Adult Tahitian Adult Tap Registration Fee Price: $25.00 Credit Card Card Details Cardholder Name