Registration
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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 Data

Student #1

Name:

 

Age:

 

    

Grade:

    

 

Interests (Select Class Times that Apply)

Ballet:

Jazz:

Summer Combo:

Hip-Hop:

Tap:

Cheerleading:

Competition:

Pointe:

Student #2

Name:

 

Age:

 

    

Grade:

    

 

Interests (Select Class Times that Apply)

Ballet:

Jazz:

Summer Combo:

Hip-Hop:

Tap:

Cheerleading:

Competition:

Pointe:

Student #3

Name:

 

Age:

 

    

Grade:

  

 

 

Interests (Select Class Times that Apply)

Ballet:

Jazz:

Summer Combo:

Hip-Hop:

Tap:

Cheerleading:

Tumbling:

Pointe:

Student #4

Name:

 

Age:

 

    

Grade:

  

 

 

Interests (Select Class Times that Apply)

Ballet:

Jazz:

Summer Combo:

Hip-Hop:

Tap:

Cheerleading:

Tumbling:

Pointe:

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