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Dansez!Dansez! Student Registration Form Registration fee: ($35 non-refundable) and tuition must be submitted with this form. Thank you!STUDENT INFORMATIONLast Name *First Name *Sex *FMDate of Birth (DOB) *Age *Allergies/ Condition Class InformationClass Type *Pre-BalletBallet 1 & 2/ IntermediateTeen BalletPre-JazzYouth JazzPre Hip-HopYouth Hip-HopPre TapYouth TapModernMummy & Me/ Daddy & Me TAPAdult Haitian FolkloreAdult Afro-Caribbean CardioAdult Zouk/ Kompa/ KizombaClass Day Class Time Prior Dance Training? *yesNoIf yes, indicate below subjects and level: Total years studied dance and where? MAIN CONTACTParent / Guardian Name(s) *Email *Home Phone *Mobile phone Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryEMERGENCY CONTACTEMERGENCY CONTACT NAME (other than parent or adult participant) Emergency Phone AUTHORIZATION & RELEASE *: Please acknowledge by checking each box below *I know of no health reasons or physical problems, other than the information indicated on this form, that would prevent my child or I from participating in any of the studio’s dance activities. I understand and agree that as parent/guardian or self, I will not hold Dansez! Dansez! liable for any injuries while at any facility or function run by Dansez! Dansez! *I further understand that there is NO deduction in tuition for missed classes, and it is my responsibility to make up missed classes. I understand that there is a $25 late fee per week for tuition payments not received by the 7th day of the month due and a $35 fee for returned checks. I authorize Dansez! Dansez! to produce pictures and videos of its students during dance classes, recitals, and concerts, to be used for internal purposes (website and dance studio displays). Your child or yourself may be captured in video taping or photo shoots.Signature *type in full nameDate ONLINE PAYMENT COMING SOON. Until then, please MAKE CHECK PAYABLE TO " DANSEZ!DANSEZ! " VerificationPlease enter any two digits with no spaces (Example: 12) *This box is for spam protection - please leave it blank:
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Phone: (202) 210-2238