Register For Dance Surge

Download the printable version of the Registration Form or Multiple Sibling Registration Form and fax to: 905-850-1844.

An asterisk (*) indicates a required field.

First Name *
Last Name *
Email *
Home Phone *
Address *
City *
Province *
Postal Code *
Age *
Birth Date *
School Grade In Sept '09 *
Health Card # *
Name of Parent / Guardian #1 *
Emergency Phone #1 *
Name of Parent / Guardian #2 *
Emergency Phone #2 *
Alternate Emergency Contact *
Emergency Phone #3 *
Medical Information (Allergies, Injuries, Other Conditions) *
I acknowledge that there is a risk of injury involved in dance and fitness classes. I accept the risk and release Dance Surge from all liability. *	Acknowledged
I acknowledge that the deposit is non-refundable, and any post-dated payments will not be returned upon withdrawal. *	Acknowledged
I allow Dance Surge to use photos/images of myself and/or my children for promotional use at any time. *	Acknowledged
Typed name as signature *

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