• Jun
    20
    2018
    Written by Laurie Oddi

    Dance Creations by Laurie

    192-21 47th Avenue

    Flushing, NY 11358

    (718) 281-2777

     

    STUDENT REGISTRATION FORM

     

    LAST NAME: _____________________________________

     

    FIRST NAME: _____________________________________

     

    DATE OF BIRTH: _________________________________

     

    STREET ADDRESS: ___________________________________________________________________________________________

     

    CITY/STATE:_____________________________________________________ ZIPCODE: ________________________________

     

    HOME PHONE NUMBER: ________________________________ CELL PHONE: ___________________________________

     

    E-MAIL ADDRESS: ____________________________________________________________________________________________

     

    IN CASE OF EMERGENCY CONTACT:

     

                    NAME: _____________________________________  PHONE NUMBER: _____________________________________

     

    DATE OF REGISTRATION: _______________________________________

     

    CLASS DAYS & TIMES:

                                                     __________________________________________________

                                                   

                                                    ___________________________________________________

     

    PLEASE LIST ANY ALLERGIES OR MEDICAL CONDITIONS WE SHOULD BE AWARE OF:

     

     

     

     

     

     

    PARENT’S SIGNATURE: _____________________________________________________ DATE: ________________________

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