REGISTER

STUDENT INFORMATION

Please note, the phone number and e-mail listed in this section will be used as our primary contact. If you would like additional people listed as contacts, please add that information in the notes box at the end of this form.

* Indicates required field

Student Name *

First

Last

d.o.b. *

Primary Email *

Street Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Is the student currently registered and active at MVDT? *

Yes No

MVDT company member? *

Yes, 2022-23 Season A Previous Season No

Do you wish to receive text alerts and reminders? *

Yes No

mvdt or capa alumni? *

Check here if you are a graduate

EMERGENCY CONTACT INFORMATION

parent/guardian #1 name *

First

Last

Parent/Guardian #2 Name *

First

Last

Email #1 *

Email #2 *

Phone Number #1 *

Phone Number #2 *

CLASS INFORMATION

I agree to receiving marketing and promotional materials

MOHAWK VALLEY DANCE THEATRE

Mohawk Valley Dance Theatre