SUMMER 2013 REGISTRATION Mongan Dance Academy

3850 W. 95th Street Evergreen Park, IL 60805 773-401-6549 Name (rst)! ! Address ! City ! ! E-mail ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! (last) ! ! ! ! ! !

Ofce Use Only Registration Fee ! # Dance Classes ! Tuition Amount ! Date Paid ! Payment Method: Cash! Check #! Credit! Debit

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Is this a cell phone? !

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NOTE: In case of an emergency of a child, the Parent/Guardian will be called rst. If he/she is not available, the Emergency Contact will be called.

Name of Emergency Contact ! Relationship to Student ! Medical Conditions !! ! !

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For students under age18 Date of Birth !! Name of School ! City of School ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Current Age !! ! ! ! ! ! ! ! ! ! ! years ! ! ! ! ! ! ! ! ! months !! ! !

School Grade in Fall !

Previous Dance Experience !

DESIRED CLASSES
Pre-Ballet Ages 2-3 Ages 3-5 Ages 5-7 Ballet Ballet I/Tap (7-10) Ballet II/Tap (10-14) Ballet III/Tap (14 & older) Other Modern (14 & older) Jazz I (5-10) Jazz II (10 & older) Hip-Hop (7 & older) Adult Zumba (16 & older)