Parent/Guardian Name

First Name

Last Name

Dancers Name *

First Name

Last Name

Dancers D.O.B *

MM

DD

YYYY

Gender:

Male

Female

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergancy Contact *

First Name

Last Name

Number *

(###)

###

####

Photographic/Video Wavier *

Do you grant us photographic & video media consent? (used for in-house and promotional use only)

Yes

No