Registration Form

* Indicates required field

Dancer's First Name *

Dancer's Date of Birth *

Dancer's Last Name *

Parent/Guardian's First Name *

Parent/Guardian's Last Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Name *

Email *

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

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