Please fill out the form below in order to expedite matters at our Open House. Class sizes are kept small so it's imperative to return registration form and payment to receive placement. Filling out this form does NOT guarantee placement. Please mail check to: Belladance 260 Rosemont Avenue Fort Thomas, KY 41075 On your check memo please include: Child's name Studio location Class Dancer Information Dancer Last Name * Dancer First Name * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Dance Experience Registering For Class * - Select -45 Minute Class75 Minute Class90 Minute ClassTwo HourOther Other Class Please specify Studio Location * - Select -Florence StudioFort Thomas Studio Parent Information Parent(s) Name * Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Home Phone Number * Is Home Number the same as cell * YesNo Parent Cell Phone Number Email Address * Emergency Contact Information Physician Name * Physician Phone Number * Does the dancer have any known medical condition or allergies? * - Select -YesNo Medical Condition/Allergies Please list and explain Release Information By typing YES, I agree to the following: the Studio will not be held liable for injury that may be encountered during dance, tumbling or any events. Release * By typing YES, I agree to the following: I give the studio permission to use my childs picture or video in any promotional or instructional material. Photo Release Box * How did you hear about us? * CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.