Dance Marathon - Register

(*) Required Fields
First Name: *
Middle Name:
Last Name: *
Email: *
Phone: *
Address 1: *
Address 2:
City: *
State: *
Zip: *
Date of Birth: *
College: *
Major:
Classification: *
How did you first hear about Dance Marathon?
Gregory Table Flyer Info Session Website Friend West Mall Table
If registering as part of a Group (NOT an organization), please indicate the name below:
Name of Group:
If registering under a specific organization, please indicate the organization:
Name of Organization:
Dietary Restrictions
Vegetarian Vegan Kosher
Allergies
Please describe:
Medical History Conditions: (Check all that Apply):
Asthma Contact Lenses Diabetic Are you insulin dependent? Epilepsy/Seizures Fractures or Dislocation (recent) Migraines Heart Problems High Blood Pressure Surgery (recent)
Emergency Contact
Name: *
Relationship: *
Address 1: *
Address 2:
City: *
State: *
Zip: *
Phone: *
Requests
If you could have one feasible wish granted during DM (not requesting to sit down or leave the premises), what would it be?:

If you could hear one song played during DM, what would it be?:

Are there any activities/games that you would like to see during DM? Which ones?:

Would you like to participate in any social events prior to the event in order to get to know more participants? If so, which ones?:

Login Information
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Password:
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