Name: Age: Date of Birth:

Address:

City: State: SC NC Zip:

Parents Name:

Home Phone: Emergency Contact:

Emergency Phone:

Dad's Place of Employment: Phone:

Mom's Place of Employment: Phone:

Total # of years student has danced (including other studios)

I would like to enroll in

Please acknowledge the following by signing after printing:

As a parent, I am fully aware of the rules and regulations of Stepping Out Dance Studio and will support and encourage my child to attend classes and achieve excellence. I also do not hold the dance studio or the staff liable for any damages or personal injuries incurred as a student or on the premises wherever classes for Stepping Out Dance Studio are held.

Parent/Guardian: ____________________________________

Date:____________________