Young School of Irish Dance

Student Information
Student 1 Name (First):
*
Student 1 Name (Last):
*
Student 1 Date of Birth (mm/dd/yy):
*

Student 2 Name (First):
Student 2 Name (Last):
Student 2 Date of Birth (mm/dd/yy):

Student Name 3 (First):
Student Name 3 (Last):
Student 3 Date of Birth (mm/dd/yy):

Young School Branch:

Previous Irish Dance experience (new students only):

If "Yes" please list school(s):
Parent/Guardian Information
Parent/Guardian 1 Name (First):
*
Parent/Guardian 1 Name (Last):
*

Parent/Guardian 2 Name (First):
Parent/Guardian 2 Name (Last):
Contact Information
Address:
*
City:
*
State:
*
Zip Code:
*

Preferred Phone # during class:
*
Home Phone w/ area code:
*
Cell Phone 1 w/ area code:
Cell Phone 2 w/ area code:
email address 1:
email address 2:
Please explain any health concerns.
Submitting this registration represents that the student(s) is(are) in good heath and do (does) not have any history of a medical or physical condition (unless specified above) that would place the student at risk because of his/her condition.

Security code:
*
Do not enter anything in this field:

* indicates a required field