EmailMe Form - 2012 - 2013 Registration Form

2012 - 2013 Registration Form
Pure Energy Dance Foudation reserves the right to cancel any class that doesn't have a minimum of 6 dancers registered.

Dancer's First Name *

Dancers Last Name *

Dancers E-mail Address

Address *

Street Address *

Address Line 2

City *

State / Province / Region *

Postal / Zip Code *

Country *

Home Phone Number *

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Students Cell Number

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Students Birthday

YYYY

Mothers Name

Prefix

First

Last

Suffix

Mothers Email

Mothers Phone Number

###

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Mothers Cell Number

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Fathers Name

Prefix

First

Last

Suffix

Fathers Email

Fathers Phone Number

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Fathers Cell Number

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Emergency Contact name *

Emergency Contact Phone Number *

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Alberta Health Care #

Medical Information:
Please describe any allergies, injuries, asthma, or medical conditions that might impair dance functions:

Checkboxes *

Tiny Toes ages 3 - 4 1st year of dance

Happy Feet ages 4 - 6 2nd year of dance

Jazz / Hip Hop ages 6 - 12

Jazz / Hip Hop ages 13 - 18

Recreational Tap ages 6 - 12

Recreational Tap ages 13 - 18

Pre-Competitive Primary ages 6 - 7

Competitive Jr. 1 ages 7 - 8 2nd year of dance

Competitive Jr. 2 ages 8 - 9 2nd year in dance

Competitive Jr. 3 ages 9 - 11 3rd year in dance

Competitive Jr. 4 ages 11 - 14 4th year in dance

Competitive Inter ages 14 - 16 must meet with Artistic Director for placement

Competitive Senior ages 16 - 20 must meet with Artistic Director for placement

How did you hear about us?

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Comments:

Dance Experience

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