A Dance Class For Me!
Schedule An Assessment Today!
About Elizabeth Rose Chacon
Current Class Location
Description, Schedule, and Cost
Review A Dance Class For Me!
Una Clase de Danza Para Mi!
Lớp Học Múa Của Em!
FAQ
Contact
Registration Form
Already had your assessment? You can complete this form to
Register for A Dance Class For Me!
Student Information (if you have more than one child enter all names and ages) use comments if you don't have enough room:
*
Indicates required field
Student's Name
*
First
Last
Student's Name
*
First
Last
Student's Age
*
Is the student on the Autism Spectrum
*
Yes
No
Prefer Not To Answer
ASSESSMENT DATE:
*
If you can remember the date of your assessment please enter it. If you are re-registering for classes just state that fact. Thank you.
Please provide any information or issues that Elizabeth Rose Chacon should be aware of (i.e. SPD, PPD-NOS, Down Syndrome Disorder, behavior issues, especially aggression.) These issues will not prevent your child from being included in class.
*
This information stays with Elizabeth Rose Chacon only and is not shared with anyone.
Parent/Caregiver Name
*
First
Last
Home Phone Number
*
Cell Phone
*
Email
*
The best way to contact you for class reminders and information is by:
*
Calling Home Phone
Calling Cell Phone
Texting to Cell Phone
Email
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Emergency Contact:
*
First
Last
Emergency Contact's Phone Number
*
Relationship to Student
*
Caregiver Named above
Parent
Grandparent
Other
Relationship If Not Listed Above
*
Please enter the relationship of Emergency Contact to the Student.
How Did You Find Out About A Dance Class For Me!? Select One
*
Autism Speaks Resource Page
Friend
Internet Search
Medical Doctor
RCOC Resource Guide
Seacliff Living Magazine
Other
If the source you needed is not listed above, please put it here.
If the way you found the class is not listed, please enter it here
*
I agree to receiving marketing and promotional materials
*
Submit
A Dance Class For Me!
Schedule An Assessment Today!
About Elizabeth Rose Chacon
Current Class Location
Description, Schedule, and Cost
Review A Dance Class For Me!
Una Clase de Danza Para Mi!
Lớp Học Múa Của Em!
FAQ
Contact
Registration Form