* Please provide the students name.
* Please provide your address.
Home Phone Work/Cell Phone:
Birthday (mm/dd/yy): Age:
Parent's Name(s):
* Please provide your email address so we can get back in touch with you.Invalid format.
Please list all the Medical concerns:
Known Allergies:
List Medications:
Emergency Contact
* Please provide an Emergency Contact. * Please provide an Emergency Phone Number.
I am a NEW student to San Benito Dance Academy (please choose one): YES NO
I am a NEW student to Dance in general (please choose one): YES NO
What type of Dance Lessons are you interested in?
(You may indicate more than one choice)		 Ballet
Adult Ballet
Other
Please list Dance types, other than those listed above that you would like to see offered:
Please list year(s) and type of Dance experience:
List the Classes & Times you are interested in:
Release Statement:
I understand that neither Kim Lavagnino nor San Benito Dance Academy, nor any other instructor carries medical insurance. Therefore, the undersigned agrees that the child(ren) are covered under my own family medical insurance policy and does not hold San Benito Dance Academy liable if an injury occurs. The undersigned understands that the student's own policy is my only source of reinbursement.
* I agree to the above release statement: Please agree to release statement to submit your info to SBDA.
Please give us any additional comments to help us improve our overall Dance program. Thank you.
 
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