Inclusive Dance Class Intake Form

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Inclusive Dance Class Intake Form

Welcome! We're excited to have you join our inclusive dance program. Please complete this form so we can best support each dancer and family. All information is confidential and used only to ensure a safe and joyful experience for all.

Dancer's First name:*

Dancer's Last name:*

Preferred Name/Nickname: (if any)

Birthday:*

Month

Day

Year

Pronouns:

She/Her

He/Him

They/Them

Other

School: (if applicable)

Grade Level:

Family & Contact Information

Caregiver 1 Name:*

Relationship to Student:*

Phone*

Email*

Caregiver Name 2 (optional):

Relationship to Student:

Phone

Emergency Contact Name (Other than above:)

Phone

About the Dancer

What interests your dancer about this class? (e.g., social, exercise, etc.)*

Please share any physical, cognitive, sensory, or emotional support needs we should be aware of to best support your dancer: (Examples: mobility aids, sensory preferences, communication methods, etc.)*

Does your dancer have a diagnosis you'd like us to be aware of? (Optional)

Are there any triggers or situations that may cause distress for your dancer?*

What helps your dancer feel safe and comfortable in new environments?*

Will your dancer be participating independently, or will they attend with a support staff person?*

Independently

With a support person

Support Person's Name/Relationship

Class Preferences & Accessibility

Has your dancer taken dance classes before?*

Yes

Do you require any accommodations for accessibility (parking, building access, communication aids, etc.)?*

Yes

If Yes, please describe:

Media Consent

We love to celebrate our dancers' achievements! Do you give permission for your dancer to be photographed or recorded for class use, promotion, or social media?*

Yes

Yes, but only for internal/classroom use

Final Notes

Is there anything else you’d like us to know about your dancer or family?

Thank you for joining our inclusive dance community! We can’t wait to move, groove, and grow together.

Home
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- Teachers and Staff
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Contact Us
2026 Recital

Fitzsimmons Dance Factory

7374 Pittsford Palmyra Rd

Fairport, NY 14450

585-425-7164

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Inclusive Dance Class Intake Form

Family & Contact Information

About the Dancer

Class Preferences & Accessibility

Media Consent

Final Notes

iClassPro Login

Find a Class or Mini Session

Inclusive Dance Class Intake Form

Family & Contact Information

About the Dancer

Class Preferences & Accessibility

Media Consent

Final Notes

Find a Class or
Mini Session