Registration Form

* Indicates required field

Dancer's First Name *

Dancer's Last Name *

Dancer's Date of Birth (MM/DD/YYYY) *

Parent/Guardian's Full Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Additional Email (Optional) *

Class Selections

Please list your class selections below.

Class *

Day *

Time *

Class *

Day *

Time *

Class *

Day *

Time *

Class *

Day *

Time *

Class *

Day *

Time *

Emergency Contact Information

Emergency Contact Name *

Relationship *

Phone Number *

Emergency Contact Name *

Relationship *

Phone Number *

Allergies or Medical Conditions *

Liability Disclaimer

By submitting this form, the parent/guardian and dancer hereby waives and releases Alison Toth and The Element Dance Company from any and all liability from all injuries that may occur in class or on the premises of the dance studio.

Select "I Agree" below if you have read and understand the Liability Disclaimer. *

I Agree

Submit