Registration Form

After 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: *

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 *

Relationship If Not Listed Above *

How Did You Find Out About A Dance Class For Me!? Select One *

If the way you found the class is not listed, please enter it here *

I agree to receiving marketing and promotional materials *

Submit

After your assessment you can complete this form toRegister 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:

After 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: