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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:
Fall Classes Summer Classes Dance Camp
Comments/Referral:
Student #1
Dancer Name:
Age:
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19+
Grade:
Interests (Select Class Times that Apply)
Ballet:
(None)
Jazz:
Preschool Combo:
Hip-Hop:
Tap:
Pointe:
Tumbling:
Lyrical:
Student #2
Preschool Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th High School
(None) Int Tap, Wed 6:45-7:15, Ages 10 Up
Student #3
Pointe::
Student #4
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Check your Junk Folder if you don't receive the Confirmation email within 3 days.