NORTHERN DANCE THEATRE 2009-2010
Dance Registration Form

this form or obtain one at the studio to mail in.
Registration fee is $30.

STUDENT’S NAME _________________________________________________
DATE I STARTED BALLET TRAINING  ________________________ ___________
CLASS(ES)   1)____________________________________________________
______2)________________________________________________________
______3)________________________________________________________
PARENT(S) NAMES ________________________________________________ 
HOME # ________________________________________________________
MAILING ADDRESS ________________________________________________
CITY __________________________________   ZIP _____________________
CELL #_____________________  WORK # _________________________   
EMAIL ______________________________
NAME ACADEMIC SCHOOL___________________________________________
GRADE ____ BIRTHDATE _____/______/______  STUDENT’S AGE as of 9/1/10____    
I give my permission to seek any emergency medical treatment for my child that might be
necessary if you are unable to contact me.
_______________________________________________________________  
Parent Signature                                                                                                  Date
Allergies_________________________________________________________
MEDICAL INSURANCE COMPANY: _____________________________________
POLICY #________________________________________________________
NAME OF PHYSICIAN  ______________________________________________
PHYSICIAN PHONE #_______________________________________________
EMERGENCY CONTACT PERSON: ______________________________________ RELATIONSHIP____________________________________________________
HOME PHONE:  ________________________WORK PHONE:________________

(PLEASE DO NOT WRITE BELOW THIS LINE) ===============================================================