Dancer’s Name ___________________________________________________________

Age __________________ Birth date ________________________

Dancer's School ________________________________ Grade ____________________

Dancer's Cell____________________ Email ____________________________________

Years ___ Ballet School _________________ Teachers _________________________

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

Mother's Name ___________________________________________________________

Business Company Name __________________________________________________

Home phone ___________________ Cell ________________Work _________________

Mailing address ___________________________________________________________

City _____________________________Zip ____________

Father's Name  ___________________________________________________________

Business Company  Name  _________________________________________________

Home phone ___________________ Cell ________________Work _________________

Mailing address ___________________________________________________________

City _____________________________Zip ____________

Other Contact Name  ______________________________________________________

Cell Phone _____________________ Work ____________________________________

New Students pay an additional $25 registration fee

Class desired Day Time Fee
 
 
TOTAL DUE ________________ ( 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 ______________