Summer Dance Intensive Registration

July 7 – 10, 2011

Personal Information

  • Name:
  • Address:
  • E-mail Address:
  • Home Telephone Number:
  • Cell Number:
  • Age:

Emergency Contact

  • Name:
  • Telephone Number(s):
  • Relationship to Dancer:

If under the age of 18

  • Parent/Guardian Name:
  • Address:
  • Telephone Number(s):

Dancer Status

  • Day Student or Boarder?

If boarding…

  • Do you have a friend attending the dance intensive that you would like to room with?
  • Any special Needs (dietary, medications etc.)?

(Boarders will be mailed additional information and questionnaires upon registration)

Payment

Please make checks payable to:  Plymouth State University

  • Amount enclosed with registration:
  • Check Number:

Full Payment Due Upon Registration