VAGANOVA WORKSHOP On-Line REGISTRATION

 

* REQUIRED INFORMATION. Please do not leave blank entries, enter the word None instead.

 

* Student’s First Name:

 

* Student’s Last Name:

 

* Date of Birth:

 

* Email Address:

 

* Home Phone:

 

* Emergency Contact Name:

 

* Emergency Contact Phone #:

 

* City:

 

* State:

 

* ZIP:

 

* Training

 

* Medical Problems:

 

* Please Select Credit Card Type: Choose Option MASTERCARD VISA

 

CC *Account Number:

 

CC Security Code #:

 

*Exp Date:

 

*Amount to Be Charged:

 

*Name on Account:

 

*CC Billing Address:

 

Please enter TEXT in image   

 

Special Needs Female Students: White leotard, pink tights, pink ballet slippers and pointe shoes.* Character Shoes Special Needs Male Students: White T-shirt, black tights, white ballet slippers Character boots or jazz shoes.

 

*** All students: Brown bag lunch. (Breakfast supplied) Notebook and pencil.