Polly B Dance Academy Contact Us

On-Line Registration Form

Classes begin: Monday, August 16th

Help us to know more about you as a dancer/potential dancer. All information will REMAIN confidential and not given to any third parties. A staff member will contact you within one day or less.

Fill out form on line by typing in and checking appropriate boxes, and do one of the following:

EMAIL by hitting Submit button at the bottom of this form
or Print it and FAX it to (904) 241-6181
Mail it or bring it to studio (Please Print a copy for your records to refer to when you visit Polly B Dance Academy)

* = Required Information

1) Student's Full Name:* Date of Birth:* Present Age:*

No. of years in dance:* With Polly B: Other:

2) 2nd Student's Full Name: Date of Birth: Present Age:

No. of years in dance: With Polly B: Other:

3) 3rd Student's Full Name: Date of Birth: Present Age:

No. of years in dance: With Polly B: Present Age:

(VIP) Name, Date & Time of class (s) request:

Family Information:

Father's Name:

Mother's Name:

Complete Mailing Address:*

City: * State:* Zip Code:*

Home Telephone Number:* Cell Number:

E-Mail Address:* Fax Number:

Place of Employment (Father and/or mother):

Business Phone:

How did you hear about Polly B Dance Academy?*