Samarpana Enrollment Form

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Student Details

Full Name *

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Date of Birth *

Age Group

5-7 yrs

8-10 yrs

11-14 yrs

14-18 yrs

18- 25 yrs

Above 25

School / College Name *

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Current Grade / Class

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Parent Name

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Relationship to Student

Select an option

Mobile Number *

WhatsApp Number (if different from Mobile number)

Residential Address *

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Bharatanatyam Background

Has the student learned Bharatanatyam before? *

No – Beginner

Yes – Learnt previously

Please mention the duration of training and previous Guru / institution. *

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Preferred class day / batch *

Tuesday and Thursday 6 - 7 PM

Weekends (Sat,Sun) 11 AM - 12 PM

Online Class - Wed, Fri 6 - 7 PM

Private classes

Student Information

Upload Student Photo *

Max file size 10MB

Are there any medical conditions, physical limitations, allergies or injuries we should be aware of? *

Yes

Please provide details of student's medical condition. *

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Anything else you would like us to know about the student?

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How did you hear about Samarpana Dance Academy? *

Google

Instagram

Reference from Friend / Family

Samarpana Name Board

Samarpana Pamphlets

Others

Consent & Declaration

I confirm that the information provided above is accurate. *

I understand that regular attendance and practice at home are important for the student's progress in Bharatanatyam. *

I agree to follow the rules and guidelines of Samarpana Dance Academy. *

I understand that fees once paid are subject to the academy's fee and cancellation policies. *

I give permission for photographs/videos taken during classes and academy events to be used for Samarpana Dance Academy's social media. *

Thank you for submitting the student registration information at Samarpana Dance Academy

We will be in touch with you. Support phone: 99008-11644

Please do not submit confidential information. Report any misuse or abuse promptly.