NAME: __________________________________________________________D.O.B. _________________


ADDRESS: _____________________________________ E-MAIL ADDRESS: ______________________


CITY: _________________________ ZIP: ______________ TELEPHONE: ( ) ____________________


EMERGENCY NO: ( )_________________________CELL PHONE # ( ) _____________________


Returning Student: YES NO


Mother & Father’s Name: ___________________________


DANCE CLASS REQUESTED: (Circle each class desired)
Pre-Ballet/Kinderdance Ballet Tap Jazz/Hip-Hop Acrobatics
Ballet/Jazz Combo. Adult Tap Adult Stretch & Tone Other ___________


Dance schools you have taken from and years attended: (Disregard this section if you are a returning student)


School:__________________________________________ Year:____________________


School:__________________________________________ Year:____________________


If new student, you heard about us by: newspaper___ yellow pages ___ internet ___ friend ___


I hereby release Cheryl A. Sullivan’s School of Dance from any and all responsibility concerning injury, theft and claims for damages which may be sustained while participating with this school. Any student who has health or physical complications that may hinder their participation in any curriculum of this school, must inform the instructor.


I have read and hereby fully understand the policies of Cheryl A. Sullivan’s School of Dance.


_____________________________ _____________________________________ DATE PARENT/GUARDIAN


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(For office use only)

CLASS REGISTERED FOR: Class: ________________ Day: ____________ Time: _____________


Class: ________________ Day: ____________ Time: _____________


REGISTRATION FEE PAID: Check # _______________ Cash ____________ Date:_____________




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