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The Boland School of Irish Dance
95 Mill Hollow Crossing Rochester, NY 14626
Ph. 723-5990 email BolandDancers@aol.com
REGISTRATION FORM 2006-2007
Student's Name
..
Address
.
Phone
DOB
Email
.
Parent's Names and phone number:
Mother
Father
Medical : Does the child have any physical/medical limitations/conditions that would affect participation in class?
Please Specify
.
With full time access to a studio, we can create a more flexible schedule. Please list your availability, for each day of the week
ranked 1= OK 2=Definitely can't make it
Sun______ Mon_____ Tues______ Wed_____ Thurs_____ Fri______ Sat_______
Please check all that apply: Reregistrant ___ New registrant ___
Is any of the above information different from last year?
.. Specify
..
If you would like to take a second weekly class check here
..
This will be scheduled only if there is adequate and appropriate enrollment.
Please return to Barbara Lussier (address above).
There is a reregistration/insurance fee of $15 per dancer for returning students and their siblings and $25 for new registrants
Studio Use only
Day
Time
..
Level
Instructor
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