registration

Pre-registration Form

Billing Name:

Relationship to Student:

Address:

City:Zip:

Home Phone: Cell:

Email:

Information Student 1 Student 2 Student 3

Name:

Birth date:

School:

Grade:

Previous Dance Training:

If Yes, please provide previous experience:

Does student have any pre-existing medical problems?

If yes, please explain:

UptownDans@aol.com

Registration Fee $125.00

247 Blue Hill Avenue

Roxbury, MA 02119

617-445-4444

Leta Tavares, Director

Registration fee includes: Payment for one costume, production fees, insurance and administrative fees.

Registration may be made online through Paypal, by mail or in person at the studio.

Signature:

Date:

"Making a Difference in Peoples lives for Over 20 Years" text.

Date:k here to add text.