WE ARE THE LONGEST RUNNING SHOW ON BROADWAY! EST. 1952
PLEASE PRINT OUT AND MAIL TO THIS ADDRESS: Jacto Dance Studio 612 Broadway Massapequa www.MassapequaDance.com
798-3738 REGISTRATION FORM
DATE____/____/____
STUDENT'S NAME____________________________ BIRTHDATE_____/_____/_____ PARENT'S NAME___________________________________ ADDRESS________________________________________ CITY_________________________ZIP____________ HOME PHONE#________________ CELL#_____________ EMAIL_________________________________________ REGULAR SCHOOL ATTENDING_____________________ SCHOOL HOURS________TO________ HOW DID YOU HEAR OF US?________________________ PREVIOUS DANCE INSTRUCTION?________ HOW LONG?____________ WHERE?__________________ DOES YOUR CHILD HAVE ANY SPECIAL NEEDS?_________