Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

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On a scale of 1 to 5 with 1 indicating that you do not feel confident, and 5 indicating that you feel very confident in your ability, rate your ability to Collaborate/Work with others? *

1 (Not Confident)

2

3

4

5 (Very Confident)

On a scale of 1 to 5 with 1 indicating not often, and 5 indicating very often, rate how often you feel/think the following: Try to open my mind. *

1 (Not Often)

2

3

4

5 (Very Often)

On a scale of 1 to 5 with 1 indicating that you do not feel confident, and 5 indicating that you feel very confident in your ability, rate your ability to Express yourself to others? *

1 (Not Confident)

2

3

4

5 (Very Confident)

On a scale of 1 to 5 with 1 indicating that you do not feel confident, and 5 indicating that you feel very confident in your ability, rate your ability to Create/choreograph dance movement? *

1 (Not Confident at all)

2

3

4

5 (Very Confident)

On a scale of 1 to 5 with 1 indicating not often, and 5 indicating very often, rate how comfortable you are sharing the following: Sharing your emotions/feelings? *

1 (Not Often)

2

3

4

5 (Very Often)