Mississauga Ballet Association

Classes held at the Living Arts Centre

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Mississauga Ballet Association
Registration From 2019/2020

Student Info

First Name *
Last Name *
Email *
Address *
City *
Province *
Postal Code *
Home Phone *
Birthdate *
Age as of Sept 2019
Years of dance training
Are you a returning dancer? No Yes

Class Code that Miss Eilleen gave you

1st Choice*
2nd Choice

Parent Info

Parent's First Name *
Parent's Last Name *
Mother or Father? Mother Father
Same address as student?
Address (if different)
City
Postal Code
Home Phone
Work Phone
Cell Phone
Email

Emergency Contact

Name *
Phone *
Allergies/Health Problems

Who will pickup the dancer?

Pickup Name *
Pickup relationship to dancer*

Sisters/Brothers in the MBA

Name
Class Level
Name
Class Level

Prefer to be called at

Home Work Cell

I would like to add a donation

$25 $50

How did you hear about MBA?

Internet Family/Friend Advertisement

Which Ad?

I have read and agree to the terms in the waiver.
Do not enter URLs.
Do not enter anything here!

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