Fall Registration 2007

Student Name:                                                                                                                      

Age:            School __________________________________ Grade                                                     

Parents Names:                                                                                                                       

Address:                                                                                                                                  

City                                                   State                    Zip                                                   

Home Phone Numbers: _________________________________________________________________

Work Phone Number:  Mom's                                                 Dad's                                                        

Cell Phone Number:   Mom's                                                 Dad's                                                          

Work Phone Number: Mom's                                                 Dad's                                                            

E-mail address (this will be used to send out reminders and updates)________________________________________________________

Emergency Contact:                                                                                                                 

Please list any medical problem/medications of which we should be aware:

 

 

Enrolling in:          

    Ballet
     Pre-Ballet / Tap (K-2nd grades)
     Hip Hop 
     Jazz
     Modern  
     Tap  
     Creative Movement (3 & 4 years old)
     Jr. Company (8 - 13 years old     (must be enrolled in ballet & modern)
     Sr. Company - by invitation only
     Ballroom dance (teens and adults, must have partner) 

Please list any previous dance training:

 

This is a pre-registration that reserves class space for your student.  You must also attend the in-house registration in July/August to schedule your student.

Mail this form with a check for $25 and save $10 on your fall registration cost.

Momentum Center for the Arts,  P.O. Box 887,  Clarksburg, WV   26301