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2187 Wehrle Drive
Williamsville, New York 14221
(716) 626-4050

Fall Registration Form (Printable)


[Click link at bottom of this page to DOWNLOAD the form]


2187 Wehrle Drive

Williamsville, NY 14221

(716) 626-4050

(Please Print)


Student’s Name ____________________________________________________________


D.O.B. (if under 18 years) __________________________  Current Age __________________


Street Address _____________________________________________________________


City ______________________________  State __________  Zip Code _________________


Home Phone ____________________________  Cell Phone __________________________


Business/Emergency Phone _________________  Email Address _________________________


Name of parent or guardian (if under 18 years)  _______________________________________



Were you one of our students last year?  Yes ________  No ________


If yes, what was the day and time of your class/classes?  _________________________________



If no, do you have previous dance experience? ________________________________________


Circle type of dance desired:  Tap, Jazz, Ballet, Acrobatics, Hip-Hop, Gymnastic Team, Other:  _________



Prefer:  Weekday Classes ________  Saturday Classes ________

(Gymnasts will be scheduled in conjunction with workout times.)


Do you have any physical limitations? ______________________________________________



How did you hear of us? _______________________________________________________


Remarks:  ________________________________________________________________





I, the undersigned will not hold Dancentral/Joyce Miller Lichtenberger responsible for the loss of, or damage to personal property or any injury sustained therein.

Signature X ___________________________________  Date ______________________ Parent or Guardian (if under 18 years)

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