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