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Adult Dance Registration Form

Ages: 20+

Classes Start Wednesday February 11th

Location: Carville Community Centre at 655 Thomas Cook Ave.

Classes run from 8pm - 9pm

Student First Name:

Student Last Name:

Address:

Birth Date: (M-D-Y)

Shirt Size

Student Email

Student Phone Number

Other: Are there any allergies or other medical condition(s) that we should be aware of ?

First Name:

Last Name:

Relationship

Contact Phone Number

Student + T-Shirt - C$98.00

Student + T-Shirt / $25 Donation - C$123.00

Student + T-Shirt / $50 Donation - C$148.00

Student + T-Shirt / $100 Donation - C$198

Student + V-Neck T-Shirt - C$98.00

Student + V-Neck T-Shirt / $25 Donation - C$123.00

Student + V-Neck T-Shirt / $50 Donation - C$148.00

Student + V-Neck T-Shirt / $100 Donation - C$198.00

*I Understand that there are NO refunds. All sales are final .*

Your Signature

I acknowledge that I have read the consent and waiver terms as well as the conditions and Policy procedures.View terms of use

I give permission for use of photograph (s) and/or video recording(s) to be submitted in newspapers, social media and promotional literature.

Please send me info on the PanMessinian Basketball Program.

Thanks for submitting!

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