Welcome to DanceAbility!
Dear Parents, We are so happy that your child will be dancing in our classes!
• To register your child, please complete this registration form & return to Boni Boswell, by e-mail
attachment: boswellb@ecu.edu; or BomnaKo: kob@ecu.edu
• Classes begin: Jan 21, 2016 (Thursday)
Please note the Thursday class times listed below. Please highlight (or circle) the
corresponding class for your child:
o Younger dancers(4-6 years) 5:00 - 5:30 pm, Minges Coliseum, DML #100
o Older children (7 to 14 yrs) 6:00 to 6:45 pm, Minges Coliseum, DML, #100
Tuition: $32/month due on first Thurs each month
• If fee reduction or scholarship is needed, please contact: Boni Boswell, boswellb@ecu.edu for information
about these options.
• All information is confidential.
The following information is confidential & only used to adapt classes to the needs of the dancers.
Child's Name: ________________________ Chronological age: _____
Parents/Guardians Name/s: ____________________________________
E-mail: _________________Phones: cell: ______________work/home: ____________
Mailing address: __________________________________________________
School: _____________ _______ Teacher: ___________________
Person/s authorized to pick up your child & their cell phone#: ______________________________
• Primary disability: _______________________________________________________
Secondary challenges? (sensory, visual/auditory?)___________________________________________
• Medical concerns (asthma, heart disorders,…) _________________________________
• __________________________________________________________________
Seizures: ______YES
______ NO; If Yes, type of seizures: _______________________________
Medications influencing movement ability?_______________________________________________
Contraindicated (harmful) Movements?__________________________________________________
• Language Skills:
Does your child use gestures, sign language or communication board? _____________________
If yes, please describe: _______________________________________________________________
Best way to communicate with your child? ________________________
_____________________________________________
• PLEASE identify strengths and needs of your child:
• Strengths: _____________________________________________________________
Physical/Motor needs: ____________________________________________________
Reinforcers:
(Please include favorites such as their favorite music, photos, books, movies, or cartoons.)
_______________________________________________________________________
• Other Misc. Info:
Please share any other information about your child that would help us to provide meaningful and fun dance
classes.
_______________________________________________________________________
• Emergency Contact (if different from phone numbers above):
Name:__________________________________
Cell/home phone: __________
Parents/Guardians Signature:_______________________
Thank you for completing this form &
Boni Boswell, PhD: boswellb@ecu.edu
Associate Professor Emeritus
East Carolina University
Department of KINE
Director, ECU DanceAbility Program
Date:____________
returning it to Boni Boswell or Bomna Ko,
Bomna Ko, PhD: kob@ecu.edu
Associate Professor
East Carolina University
Department of KINE
Vice Chair, DanceAbility Advisory
Council