Parents' Names:

____________________________________________________

Address:

____________________________________________________

Town:

_____________________________

ZIP: _____________

Telephone:

  (      )  ________________

  (      )  ___________________

Home

Cell

  (      )  ________________

   __________________________

Emergency

E-Mail

Student's Name:

____________________________________________________

Birthday:

_____________

Age:

   _________

[     ] 

Please check here if there is any special information that we should

know about your child/children and list it on the back of this form.

       I agree to comply with the rules and regulations of Diane's Dance Center, Inc.

I certify that my child is in good physical health and hereby give my permission for the

above named student to participate in the Summer Intensive Program at Diane's Dance

Center, Inc.

Signature:

___________________________

        Date: ___________________

                 [Parent or guardian if under 18 years of age]