KCDC - Dance Center | Student Enrolment

Application Form

First Name:
Last Name:
Gender:	Male Female
Address:
City:
State(US&CA):
Zip Code:
Country:
Email:
Date of Birth:
Phone:
Cell Phone:
Contact Person Name: (Mother, Father, Sister) (In case of emergency)
Contact Person's Phone: (In case of emergency)
Do you have a medical insurance for Europe:	Yes No
Registering for program:
Date for register for:
Your Dancing Experience:
Presently Training At:
Any disability? (If yes, please specify here)
Additional information or remarks:
By submitting this form I agree to pay the registration / Processing fee of 300$ (150 $ Refundable only if cancelled 30 days before starting your program) upon registration, in order to secure my place. The balance to be paid on arrival in israel.
You will receive an email confirmation with instructions how to pay