SPRING DANCE ENROLLMENT FORM
STUDENT INFORMATION
Last Name *
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First Name *
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Age *
Your answer
Grade *
Your answer
PARENT INFORMATION
Parent Name (Primary Contact) *
Your answer
Parent Name (Other Parent/Guardian)
Your answer
Primary Phone (XXX-XXX-XXXX) *
Your answer
Phone (Home or other Parent/Guardian)
Your answer
Student Phone
Your answer
Email (Primary Contact) *
Your answer
Email (Other Parent/Guardian)
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Student Email
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School
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Street Address (Primary) *
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Town *
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Zip Code *
Your answer
Street Address (Other Parent/Guardian, if different from above)
Your answer
Town
Your answer
Zip Code
Your answer
EMERGENCY CONTACT INFORMATION
(OTHER THAN PARENT)
E.C. First Name *
Your answer
E.C. Last Name *
Your answer
E.C. Phone (XXX-XXX-XXXX) *
Your answer
E.C. Relation to Child *
Your answer
CLOTHING SIZES
(For costumer)
Shirt Size (Please Specify youth or adult) *
Your answer
Pant Size/Dress Size (Please include waste & length, if applicable) *
Your answer
Shoe Size *
Your answer
CLASS SELECTION
Tap with Cylie Kindvall
Hip Hop with Bianca Zogbi
Ballet/ Jazz with Bidalia E. Albanese
PAYMENT INFORMATION
If paying by check, our mailing address is as follows.

23 Elephants Theatre Company
PO Box 1939
San Anselmo, CA 94979
Dance Classes are $300 for enrollment in one class, $285 per class for enrollment in 2 classes, or $270 per class for enrollment in 3 classes. *
MEDICAL AUTHORIZATION/PHOTO & VIDEO RELEASE
By checking this box, I hereby agree to indemnify and hold harmless 23 Elephants Theatre Company and its officers and employees from and against any and all liabilities for any injury which may be suffered by me or my child arising out of or in any way connected with participation in the program noted above. In case of an emergency, my child may be treated by a qualified physician. I give 23 Elephants Theatre Company permission to use photographs and/or videos of my child in brochures or publicity. *
Required
REFUND POLICY
If there is insufficient enrollment, the production/ class will be cancelled and your money refunded. Withdrawal from the production/class will incur a $100 fee. Withdrawal requests must be made by the first day of the production/class. THERE WILL BE NO REFUNDS AFTER THE FIRST DAY OF THE PRODUCTION/CLASS. *
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