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Pickerington Dance Academy Student Registration

Parent/Guardian Data

PARENT First Name:

 Last Name:

Street Address:

City / State:

     

Zip Code:

E-mail Address:

Home Phone:

Session:

Comments/Referral:

 

Student #1

Dancer Name:

 

Age:

 

Grade:

Interests (Select Class Times that Apply)

Ballet:

Jazz:

Preschool Combo:

Hip-Hop:

Tap:

Pointe:

Tumbling:

Lyrical:

Student #2

Dancer Name:

 

Age:

 

Grade:

 

Interests (Select Class Times that Apply)

Ballet:

Jazz:

Preschool Combo:

Hip-Hop:

Tap:

Pointe:

Tumbling:

Lyrical:

Student #3

Dancer Name:

 

Age:

 

Grade:

 

Interests (Select Class Times that Apply)

Ballet:

Jazz:

Preschool Combo:

Hip-Hop:

Tap:

Pointe::

Tumbling:

Lyrical:

Student #4

Dancer Name:

 

Age:

 

Grade:

 

Interests (Select Class Times that Apply)

Ballet:

Jazz:

Preschool Combo:

Hip-Hop:

Tap:

Pointe::

Tumbling:

Lyrical:

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Check your Junk Folder if you don't receive the Confirmation email within 3 days.