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

Class/program selection *

Leap & Twirl (age 2-3)

Pre-Primary Ballet (FULL - waitlist only)

Primary Ballet (age 5-7)

Ballet

Teen/Adult Ballet

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