Youth Membership signup Form

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Please fill out the form. All information is kept completely confidential and is for Manga African Dance internal use ONLY.

PLEASE NOTE: Once we have processed your information, you will meet with the Artistic Director to talk more about your new membership and complete the registration process. Thank-you for choosing Manga African Dance!

Email *

Student's First Name *

Student's Last Name *

Student's Date of Birth *

Primary Email Address *

Street Address *

City, State, zip *

Mother's Name *

First & Last

Mother's home #

Mother's cell # *

Father's Name *

Father's home #

Father's cell # *

Alternate Contact Name *

Manga wil only contact this person if parents are unreachable and child has not been picked up.

Alt. Contact's Relationship to student *

Alt. Contact Phone # *

Allergies, Medical Conditions, Medications *

Please tell us about any medical conditions that your child has .

How Did you Hear about us? *

Please check all that apply.

Internet Search Engine

Followed Link from Another Website

T.V.

Radio

Magazine/Newspaper

Blog/Forum

Social Internet Network (Facebook, Myspace)

Flyer/poster

Online Newsletter

Word of Mouth

I am a return client

Other:

Required

I was referred by:

Please let us know if you were referred by a friend!

Additional Comments

Please feel free to contact us with any questions. email:mangadance@yahoo.com (404) 462-5723

Send me a copy of my responses.

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