Club Membership Registration Form

Dance Dojo Dance Membership Registration

Complete the form below to sign up for our membership service.
Name

First NameLast Name
E-mail
Phone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date:

MonthDayYear
Where did you hear about us?

Friend or familyInstagramFacebookGoogleYoutubeOther
Do you have any medical conditions or injuries that may affect your ability to participate in our classes?

YesNo
If yes, what are they?
Is there any history in your family of:

DiabetesHigh Blood PressureHeart TroubleStroke
Do you have any specific fitness goals?

YesNo
If yes, what are they?
If you are interested in dance/fitness classes that are not currently offered by Dance Dojo Dance, what type of classes are they?
Emergency Contact
Signature*

Clear
Date
Should be Empty:

Dance Dojo Dance Membership Registration