Adult Registration

Information
Name*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Emergency Phone*
Permission Emergency/Medical Treatment
In 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 ZIP Code
Choose Dance Classes*
- Adult Hip-Hop
- Adult Floor Barre
- Adult Tahitian
- Adult Tap
Registration Fee*
- Pay Online
- Pay In Person
Registration Fee
Price:
Credit Card
Card Details
Cardholder Name

Information