Student Information
First Name:
Last Name:
Age:
Birthday
Grade in 2012/2013 School Year:
Academic School:
School District:
Phone: (xxx-xxx-xxxx)
Day:
Evening:
Email:
Parent/Guardian Information (Only for students under the age of 18)
Mother:
Father:
Address:
OCCUPATION
Mother:
Employer:
Father:
Employer:
Emergency Contact
Name:
Phone:
Address:
Any preexisting medical conditions? If yes, please Explain:
General Information
How did you hear about Nrityala Dance Academy?
Please print clearly the way you would like your child's name to be announced during
Performances:
Nrityalaya Dance Academy
Student Registration Form