Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent/Guardian Name(s) *

First Name

Last Name

Phone *

(###)

###

####

Alternate Contact Phone

The phone number of anyone else we may contact if the primary contact can't be reached.

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Program selection *

Select all that apply.

Leap & Twirl

Primary Ballet

Summer Swans

Ballet 4 -5 (Session 1)

Ballet 4 -5 (Session 2)

Pointe (Session 1)

Pointe (Session 2)

Pre-Pointe

Elite Intensive (July 8 -12)

Elite Intensive (July 15 - 19)

Media release *

Photos may be taken in class from time to time. Do you give permission for Genesee Dance Theatre to use your child's photograph in publicity and marketing materials?

Yes

Yes, only without child's name included

No

Terms of enrollment

I understand that my dancer's enrollment will not be finalized until my enrollment deposit is paid. I understand that my deposit is non-refundable.

Yes