Do not write in this space Reg. pd______________ Check #_____________
Total paid: _________________ Bal. due:_____________
Mailing Address City/State: Zip
Home: Cell
Pay by: Paypal on site
In case of emergency call: Name:
Phone:
Cell:
List Dance Training: Studied: (circle) ballet, pointe, jazz, tap, hip hop, other: Where: Number of years: List any physical limitations: Injuries: How did you hear about us? (please check) Website Friend Driving By Phone Book Newspaper Other:
Session: Your start date to Check: Child Teen Adult Enrolling for: (circle) Mon. Tues. Wed. Thurs. Fri. Sat.
Circle: * Ballet * Pointe * Tap * Jazz * Hip Hop * Other: ______________________________ Combination Class: * Tap & Ballet * School Year Season
Class space is reserved. Therefore no refunds or credits can be given for missed or dropped classes . Registration fee, deposits or tuition will not be refunded.
The parent or adult student signing this release acknowledges our policy as stated on the tuition form and understands that his/her child or adult student is taking classes at his/her own risk and agrees to hold Civic Dance Center. its instructors, and/or assignees harmless in the event of any physical injury to the student. Person signing this form is responsible for payment of registration fee, and/or tuition. Registration Fee is $25.00 (New Students) $20.00 (Returning Students) $30.00 Per Family (New/And or returning students). Please enclose with registration form. Tuition enclosed: $ or deposit of $ is enclosed. Check #
X X Date Today Parent or Guardian Signature / Adult Student Signature
