Student’s Name __________________________________________________________________

Date of Birth ____________ Age ______ New or Existing Student ________________________

If New Student, how did you hear about Center Stage Dance Company?

___ Friend/Family ___ Website ___ Ad in CV Kids Directory

___ Desert Welcome ___ Flyer at Local Business ___ Radio Advertising

___ Yellow Pages ___ Other (please explain) ________________________________________

Siblings Also Enrolled _____________________________________________________________

Parent’s Name(s) _________________________________________________________________

Home # _________________ Cell #____________________ Work #_____________________

Mailing Address __________________________________________________________________

City ____________________ Zip ________ Email Address ______________________________

Emergency Contact Name & Phone # ________________________________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Paid by: Check ________ Cash ____ Amount Paid $__________

Class Day & Time ________________________________________________________________

Class Day & Time ________________________________________________________________

Class Day & Time ________________________________________________________________

Class Day & Time ________________________________________________________________

Class Day & Time ________________________________________________________________

Class Day & Time ________________________________________________________________

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