Duxbury Dance Shoppe

114 Pembroke Street       Kingston, MA.   02364      (781)585-2588

DUXBURY DANCE SHOPPE

REGISTRATION FORM

FOR the 2016/2017 DANCE SEASON


STUDENT'S NAME:________________________________________________________


aDDRESS:_______________________________________________________________


TOWN & ZIP CODE:_______________________________________________________


HOME PHONE:______________________________ CELL:________________________


EMAIL:_________________________________________________________________


BIRTHDATE:_____________________________________________________________



                          alLERGIES OR MEDICAL CONDITIONS:___________________________________________________

(all conditions will be confidential)



registration fee before june 1st is $10

after june 1st the registration fee is $15


class day & time registering for:_______________________________________