A Dance Class For Me!
Schedule An Assessment Today!
Registration Form
Current Class Location
Class Descriptions
Una Clase de Danza Para Mi!
Clases en 2021
About the Provider (en Espaῆol)
Cost of Classes COVID
Contact Elizabeth
Members Only
About the Provider
Resources
FAQ
Lớp Học Múa Của Em!
Contact/Contacto/LIÊN LẠC
Please complete this form to
Register for A Dance Class For Me!
after your child's Assessment
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
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, etc. These issues will not prevent your child from being included in class.)
*
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!
Registration Form
Current Class Location
Class Descriptions
Una Clase de Danza Para Mi!
Clases en 2021
About the Provider (en Espaῆol)
Cost of Classes COVID
Contact Elizabeth
Members Only
About the Provider
Resources
FAQ
Lớp Học Múa Của Em!
Contact/Contacto/LIÊN LẠC