LLC.

School of Dance and Kinetic Expression

202 E. Douglas, Canon City
Owner/Artistic Director: Brittany Martell
719-289-6751
dancetheb_box@yahoo.com
www.facebook.com/DanceTheB.Box

Registration Form
Parent 1Last Name: ____________________________ First Name: _____________________
Home phone: ____________ Cell phone: ___________ Work Phone: ___________
Address: _____________________________ City: _________________ zip: _______
Email Address: _____________________ Secondary Email: ___________________

Parent 2Last Name: ____________________________ First Name: _____________________

Home phone: ____________ Cell phone: ___________ Work Phone: ___________
Address (if different from above): _________________ City: _________ zip: _________
Email Address: _____________________ Secondary Email: ___________________

Student(s)1. Name (Last, First): _________________ Nickname? ___________ DOB________

2. Name (Last, First): _________________ Nickname? ___________ DOB________
3. Name (Last, First): _________________ Nickname? ___________ DOB ________

Is there a student email or phone number that you would like to provide us
with so that we might better keep your family informed?
________________________________________________________________________
________________________________________________________________________

Doctors Name/phone: ___________________________________________________

Is there any medical history, disabilities, allergies, or other medical information

we should be aware of to better serve you and your child?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Are there any behavioral or emotional challenges we should be aware of to

better serve you and your child?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Is there anything else you would like to tell us about your child?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________