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Chance to Dance 2019 Registration
Open to: All male and female Scottish Rite Hospital patients between the ages 5 and 12, and their siblings and friends.
Class location: Texas Scottish Rite Hospital for Children
2222 Welborn Street
Dallas, TX 75219
Maple A&B (1st Floor A-Building)
Class schedule: Every Tuesday, February 12 - March 19 6:30 - 7:30 p.m.
Final performance: Tuesday, March 19 from 6:30 - 7:30 p.m.
Please note: Parents/- Guardians must remain on campus during class.

Contact: Mackenzi Summers, M.S., CTRS
214-559-8345
mackenzi.summers@tsrh.org

Participant last name (apellido del participante) *
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Participant first name (nombre del participante) *
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Participant DOB (mes /día /año) *
MM
/
DD
/
YYYY
Participant Age (edad del participante) *
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Parents/ Guardians Name (nombre de los padres) *
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Relation to Participant (relación al participante) *
Preferred Email (su correo electrónico) *
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Preferred Phone Number (el número de teléfono) *
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Preferred Language (Idioma preferido) *
Specific Mobility Devices (dispositivos de movilidad)
Will participant need assistance ? (¿Participante se necesitarán ayuda?) *
If yes, please describe assistance needed (Si la respuesta es afirmativa, describa la asistencia necesaria)
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Will siblings/ friends be participating ? (¿Van a los hermanos / amigos participar?) *
Name and age of siblings/ friends attending & relation to participant (ex: Mackenzi, 7 - Sister) (Nombre y edad de los hermanos/amigos asistiendo y el relación al participante.)
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