View more information about the Summer Schedule here! NOTICE: Confirmation of class will be confirmed when full payment has been received. 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 Remember class size is limited, enrollment is on a first come first serve basis. Dancer Information Dancer Last Name * Dancer First Name * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Dance Experience Studio Location * - Select -Florence StudioFort Thomas Studio Florence Registering For Class * Dance Team Clinic ($95)Belladance Ballet Boogie ($55)Summer Technique Intensive ($75) Notice: The Dance Team Clinic is taught at the Fort Thomas location. Fort Thomas Registering For Class * Dance Team Clinic ($95)Belladance Ballet Boogie ($55)Bella's Summer Technique Intensive ($75)Tap Dogs ($60) 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.