TAPA registration

Child's Name

Age *

Address *

Enrolled in Program:
(name of school and/or program)

Name of Parent/Guardian *

Address
(if different from above)

Phone

E-Mail *

Person to contact in case of an emergency

Emergency Contact Number

Special Needs
Please note: Children using wheelchairs must be able to transfer by themselves or the family must provide a personal attendant. Personal attendants also need to send in a registration form.

Cerebral PalsyDown SyndromeAutismAutism SpectrumLearning disabilities/delaysOther

If you check other please describe
(including physical disabilities)

My Special Interests Are
*(performance based) Students perform after every 12-15 week series
**Classes are held from 9-12 Tues. – Fri. Must be accompanied by an adult

Dance Club*BalletTapJazzMusical TheatreCreative MovementDrama Club*ArtMusicBaby, Crawler and Toddler classes**

A good DAY for me to take class(es) is: (CHECK ALL THAT APPLY)
*not available this semester

TuesdayWednesdayThursdayFriday*Saturday*

The best TIME for me to take class is:
Check all that apply
A 15 min. transition time is given between each class session

4 - 4:455 - 5:456 - 6:457 - 7:45

or Reset

The Theresa Alessandra Russo Foundation | 250 Lido Blvd. | Lido Beach, NY 11561 | (516) 432-0200 | Fax (516) 432-0449