Subject: *
White Lotus Ballet Online Registration

Student's Name: *


Age: *


Address: *


Town/City: *


Date of Birth: *


State: *


Zip: *


Phone Number(s): *


Email: *


Parent(s)/Guardian(s): *


Classes interested in:
Check off all that apply below!

First Steps

Nursery Dance

Kinder Dance

Ballet Intro

Ballet I
Select A or B Class:

A

B

Ballet II

Ballet III
Select A or B Class:

A

B

White Lotus Workout

Prior Dance Experience: *


Physical Restraints/Development Concerns: *


What would you (the student) like to gain from your dance class? *


What would you (the parent) like the student to gain from their dance class? *


How did you hear about Lotus Ballet? *


Payment Method: *
CashCheck

Please make checks payable to White Lotus Ballet.

***In order to conform to the dress code you may purchase the needed attire from Balletomania located at:
7345 S. Broadway in Red Hook or at 2 Tucker Road in Poughkeepsie.

Please inform the sales assistant that you are with White Lotus Ballet and she will direct you to the appropriate selection. Thank you.