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Step It Up Registration Form
This is the official form to register as a student of our studio.
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* Indicates required question
Parent(s)/Guardian:
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
Address:
*
Your answer
City, State, Zip
*
Your answer
Phone Number:
*
Your answer
Second Phone Number:
Your answer
Email address:
*
Your answer
Emergency Contact (other than parents):
*
Your answer
Contact Phone Number:
*
Your answer
Student Information
Student Name:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Student 2 Name:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Student 3 Name:
*
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Student 4 Name:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Medical Information
Has the student(s) had any serious injuries?
*
Yes
No
If yes, please explain:
Your answer
Does the student(s) take any medications on a regular basis?
*
Yes
No
If yes, please explain:
Your answer
Does the student(s) require any special medical care?
*
Yes
No
If yes, please explain:
Your answer
Doctor's Name:
*
Your answer
Doctor's Phone Number:
*
Your answer
Hospital
*
Your answer
Hospital Phone Number:
*
Your answer
Any additional information we should know about the student(s)?
Your answer
How did you hear about us?
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