| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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| College Attending: |
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| Major:: |
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| Current GPA:: |
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| Current Status: (Enter Highest Grade Level Completed): |
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| Dept .Head or Contact Person Name:: |
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| Contact Phone:: |
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| Please explain your desire for pursuing this internship position? |
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| Please list your dance experience and classes taken? |
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| Please list any prior experience working with children? |
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| Are you able to produce simple choreography? |
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