Print page and send with $45.00 registration fee to: Lynette's Dance Studio
3076 - 38 Avenue
Columbus NE 68601
Student's Name ____________________________________________________________
Birthdate _________________________________________
Age ____________________
School ___________________________________________
Grade ___________________ (fall of 2012)
Parent(s) Name ___________________________________________________________
_________________________________________________________________________
Address _________________________________________________________________
Phone Number ___________________________________________________________
Cell Phone Number ________________________________________________________
E-mail Address ___________________________________________________________
Dancer's E-mail Address _____________________________________________________
Fill in E-mail address ONLY if you check your e-mail.