Application Form

Cincinnati Dance Academy
Registration Form 2004 - 2005

This is an electronic form.
You can fill it out while on-line.
Print, Sign and Date this form.
Mail to the address at the bottom of the page.

Student Information:
Student's Name
Date of Birth	,
Years in Dance
Student's E-mail
Parental Information:
Parent's Name
Address
City
State
Zip
Phone	Day:-- Evening:--
E-mail
Emergency Information:
Emergency Contact
Phone	--
Doctor's Name
Phone	--
Medical Conditions
Class Information:
Class Name
Instructor
Class Day & Time	Day: Time:
Class Name
Instructor
Class Day & Time	Day: Time:
Recommended by
Injury Release Form:
I, , hereby release Cincinnati Dance Academy and/or Tatyana Makarova, of any injuries that may occur to while on the premises of the above named studio or while participating in any classes. Please sign & date after printing Signature Date
Return this form and $20.00 Registration Fee to: Cincinnati Dance Academy 4122 E. Galbraith Rd., Cincinnati, OH 45236 513.985.0111 Thank You for choosing Cincinnati Dance Academy. Tatyana Makarova, Director