Stephens Dance Studios

Preferred Class Day:

________    Tuesday Crescent Springs        _________ Wednesday Ft Thomas

Student: _____________________________     Age: ______       DOB: ___________

Health Conditions/ Allergies (asthma, peanuts, etc.): Previous Dance:

__________

Student: _____________________________     Age: ______       DOB: ___________

Health Conditions/ Allergies (asthma, peanuts, etc.): Previous Dance:

__________

Parent/Guardian: _________________________________            Daytime Telephone: ____________________

Address: _________________________________________ Eve Telephone: __________________________

City___________________ State ________ Zip ___________      Cell Phone: _____________________________

Mail to:

Stephens Dance Studio

PO Box 1475

Florence, KY 41022-1475

                        Name of person transporting student:

____________________________________                Phone: ___________________ 

                        Name of person responsible for payments:

______________________________________                Phone: _____________________