Dancer’s Name ___________________________________________________________

Age __________________ Birth date ________________________

Dancer's School ________________________________ Grade ____________________

Dancer's Cell____________________ Email ____________________________________

Parents' Email ____________________________________________________________
Go to classdesired next if the following data is already on file

Home Phone _______________________

Mailing address ___________________________________________________________

City _____________________________Zip ____________

Mother's Name ___________________________________________________________

Cell phone _____________________ Work ____________________________________

Father's Name  ___________________________________________________________

Cell phone ____________________   Work ____________________________________

Other Contact Name  ______________________________________________________

Cell Phone _____________________ Work ____________________________________

Class desired Day Time Fee
 
 
TOTAL DUE ________________ ( Starting with the Summer Session, late payments will be charged a late fee of $25)

Location: Dole Cannery  _______     Wahiawa _______     Kapolei _____

Credit Card #_______________________________________________

Exp Date ___________   Signature_________________________________________

FOR OFFICE USE: CC ______  Amt. paid ______ Ck # ______    Date paid ______________