MUCAI Academy

 2010/2011 Registration Form

 

 

Student Name ____________________________________________ Age ____ Date of Birth ________

Address_________________________________________________ Home Phone ________________

Email: _________________________________________________________________

School District ______________________ Grade Entering ______ School _______________________

Parent/Legal Guardian(s): _______________________________ Phone __________________

                                           _______________________________ Phone _________________

Emergency Contact(s):      ______________________________  Phone __________________

                                           ______________________________  Phone__________________

 

Permission to administer first aid/CPR            Yes          No (I acknowledge and accept all medical and/or legal consequences)

Permission for EM or hospital to administer

medical treatment                                            Yes         No (I acknowledge and accept all medical and/or legal consequences)

Permission to transport                                        Yes         No

 

What are your interests?:

                   Dance Classes      Coaching      Performances Opportunities  

 

Check all that apply:

 

   ____ Ballet                                ____ Pointe                            

   ____ Modern                         ____ Hip Hop

   ____ Tap                                   

   ____ Jazz

   ____ Elements of Dance (Includes all pre-school level classes)                            

   ____ Discover Dance (General Dance Education Class - covers basics of all genres)

   ____ Floore-Barre (Ballet Strengthening and Conditioning Class)

 

Years of experience:     Ballet______    Pointe______   Tap_____    Jazz______   Modern_______  

                                      Theatre Dance ______   Hip Hop______   Performance _______

 

 

Special needs, health concerns, injuries in the last 2 years: ____________________________________________________________________________________

____________________________________________________________________________________

 

Parent Signature _________________________________ Date _________________________

Students Signature (if over 18): _____________________________________ Date ________________