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DANCE ME IN

Registration

To register, please take the time to fill out the information below.

First Name

Last Name

Email

Phone

Birthday

Address

We need your permission

mailing address: 1014 Hope St. B7

Bristol, R.I. 02809

E-Mail: sue@dtdballroom.net

Tel: 401-230-3420

First Name

Last Name

Your name here gives permission for the Dance Me In program to use photos and/ or videos showing your likeness for promotional purposes.

Thanks for submitting!

DANCE Health Waiver

To register to our dance program please fill out the following medical form

First Name

Primary Care physician:

Last Name

Physician's Phone

Do you have a doctor’s permit to participate in physical activities?

No

Yes

Have you lost your consciousness in the last past 12 months?

No

Yes

Initials of participant, parent, or guardian

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

ADDRESS

1014 Hope St B7
Bristol, R.I. 02809

CONTACT

401.230.3420
sue@dtdballroom.net

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