I. Personal Information
Student’s Name ________________________ Age _________Birthday______________
Parents’ Names___________________________________________________________
Address _______________________________________________________________
Home Phone ________________ Cell Phone ________________ Cell Phone___________
Contact in case of emergency _______________________________________________
Physical/ mental conditions we should be aware of ______________________________
Email Address ____________________________ Number of years of dance training______
Referred by __________________________
II. Class Information
Ages 3-5
___ Tiny Tot Monday 5:30-6:00 ___ Tiny Tot Friday 11:00-11:30
Ages 5-6
___ Mini 1 Tuesday 6:15-6:45 ___ Mini 1 Thursday 6:15-6:45 ___ Mini 1 Friday 12:30-1:00
Ages 6-8
___ Mini 2 Hip Hop ___ Mini 2 Ballet ___ Mini 2 Tap ___ Mini 2 Jazz
___ I am interested in learning more about the performance team.
___ I am interested in learning more about the competitive team.
Ages 8-12
___ Junior 1 Ballet ___ Junior 1 Hip Hop ___ Junior 1 Tap ___ Junior 1 Jazz
___ I am interested in learning more about the performance team.
Ages 13-18
___ Teen Hip Hop Wednesday 7:00-7:30 ___ Teen Jazz Wednesday 7:30-8:00
___ I am interested in learning more about the performance team.
Ages 13-18
___ Teen Tap Tuesday 7:00-7:30 ___ Teen Jazz Tuesday 7:30-8:00
___ Teen Contemporary Wednesday 4:30-5:15 ___ Teen Ballet Wednesday 5:15-6:15
___Teen Pointe Wednesday 6:15-7:00 ___ Teen Hip HopThursday 7:00-7:45
___ I am interested in learning more about the performance team.
___ I am interested in learning more about the competitive team.
Boys Ages 6-18
___ Hip Hop Friday 5:00-5:30 ___ Jazz Friday 5:30-6:00 ___ Tap Friday 6:00-6:30
___ I am interested in learning more about the performance team
___ I am interested in learning more about the competitive team.
Adults Ages 18 and up
___Adults Friday 1:00-2:00
___ I am interested in learning more about the performance team
Company Members
Petite 1
Packages: ___Basic Package ___Deluxe Package with (circle one) Tap or Hip Hop ___Premiere Package
Tracks: ___ Track 1 ___Track 2 ___Track 3
Competitions: ___Silver Plan ___Gold Plan ___Platinum Plan
Petite 2
Packages: ___Basic Package ___Deluxe Package with (circle one) Tap or Hip Hop ___Premiere Package
Tracks: ___ Track 1 ___Track 2 ___Track 3 ___Track 4
Competitions: ___Silver Plan ___Gold Plan ___Platinum Plan
Junior 2
Packages: ___Basic Package ___Deluxe Package with (circle one) Tap or Hip Hop ___Premiere Package
Tracks: ___ Track 1 ___Track 2 ___Track 3 ___Track 4
Competitions: ___Silver Plan ___Gold Plan ___Platinum Plan
Teen 3
Packages: ___Basic Package ___Deluxe Package with (circle one) Tap or Hip Hop ___Premiere Package
Tracks: ___ Track 1 ___Track 2 ___Track 3 ___Track 4
Competitions: ___Silver Plan ___Gold Plan ___Platinum Plan
III. Payment Information
___Month to Month ___12 Month Membership ___Year up front ___Semester up front
Signature for 12 Month Membership____________________________________________
Payments can be made by cash, check, credit card, or direct debit.
Wavier: There is a risk of injury when participating in any form of movement. Essentials Dance Company and Gymstars are not liable for any injury sustained in or around the property located at 435 Washington Street Ste. 102.
Signature of Parent or Guardian ___________________________________________
Today's Date___________________
