2019 SSSOD Summer Registration Form
Please use this form to register for Summer dance classes at the Newman YMCA's, Shooting Stars School of Dance.
Email address *
Child's First Name *
Your answer
Child's Middle Name *
Your answer
Child's Last Name *
Your answer
Date of Birth *
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Age *
Your answer
Gender *
Grade Entering Fall 2019 *
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Primary Parent/Guardian Contact Name (First and Last) *
Your answer
Primary Parent/Guardian Date of Birth *
MM
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DD
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YYYY
Primary Parent/Guardian Address *
Your answer
Primary Parent/ Guardian Phone Number. Please include area code and if it is your cell, work or home number. *
Your answer
Primary Parent/Guardian Contact Email *
Your answer
Primary Parent/Guardian Additional Phone Number(s). Please include area code and if it is your cell, work or home number. *
Your answer
Secondary Parent/Guardian Name (First and Last)
Your answer
Secondary Parent/Guardian Date of Birth
MM
/
DD
/
YYYY
Secondary Parent/Guardian Address
Your answer
Secondary Parent/Guardian Phone Number. Please include area code and if it is your cell, work or home number.
Your answer
Secondary Parent/Guardian Email
Your answer
Secondary Parent/Guardian Additional Phone Number(s). Please include area code and if it is your cell, work or home number.
Your answer
#1 Emergency Contact/ Authorized Pick-up
Your answer
#2 Emergency Contact/ Authorized Pick-up
Your answer
#3 Emergency Contact/ Authorized Pick-up
Your answer
2019 Summer Class Enrollment Agreement (Please Check All) *
Required
I clearly understand all of the policies and procedures listed above.
Does your child have any allergies? If yes, please explain in "other".
Does your child take any medications? If yes, please explain in "other". *
Your answer
Are there any special instructions that we should be aware of (disability, unauthorized pick-ups, special learning requirements, etc.).
Your answer
Please select the classes you wish to enroll below.
Toddler- 2nd Grade (Please use the "other" option if you do not see that you want listed) *
Required
3rd Grade & Up (Please use the "other" option if you do not see that you want listed)
Is your child is interested taking a private or semi-private lesson?
If your child is interested in taking a private lesson, please indicate the style your child would like to perform/study, your instructor preference (list at least two) and the day and times that work well for you. Additionally list the dancers you plan to have the lesson with if you are enrolling in a duo/trio or small group. Please note this does not guarantee your selected time or instructor.
Your answer
Summer Tuition for Reference
Payment Plan for Summer Tuition *
Please select your PAYMENT METHOD: If you choose "ACCOUNT ON FILE" and have multiple accounts on file you you must specify which account you wish to use. If you do not specify the account used for your YMCA membership (members) or past dance tuition drafts (non-members) will be used. If you are new to the program or would like to add a new account we will be contacting you shortly.
By submitting this form, I hereby understand that I am enrolling in the 2019 Summer Dance Program for the Newman YMCA's, Shooting Stars School of Dance. Please type the name of the person filling out this form. *
Your answer
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