Registration

 

      
Fall 2011/2012 Registration Form

 

 

Student’s Name______________________________ Grade 2011/2012___________ Age________ Birthdate _____/_____/_____

Parent’s Name______________________________ Home Phone_______________________ Cell__________________________

Address_____________________________________________ City_______________________ Zip_______________

Email (required)_____________________________________________________________

 

I would like to make monthly payments by (please circle one) cash/check Visa Mastercard Discover

Name on Card_______________________________________________________

Credit card #________________________________________________________ Exp Date__________________

Signature_________________________________________________________________

 

Liability Waiver and Class Cancellation

 

I, the undersigned have read through all registration and tuition information. I understand that I am responsible for all tuition payments. In the case of withdrawal from class, I understand that I am financially responsible for all tuition incurred. Select Dance Academy and Performing Arts Center is not responsible for any lost or stolen items from the Select Dance Academy premises or from Select Dance Academy events, competitions, or recitals.

In consideration of the opportunity to participate in the classes and programs of Select Dance Academy & Performing Arts Center, I release and discharge Select Dance Academy & Performing Arts Center, its Directors and Agents from any claims, demands, liabilities or damage arising from the participation of my child in any classes or programs sponsored by Select Dance Academy & Performing Arts Center. If the parents or Emer-gency contact cannot be reached in case of an emergency, consent is given for my child to receive medical or surgical care as recommended by the physician or hospital.

Parent Signature_____________________________________________ Date__________________________________

 

 

Class Name  Day  Time  Cost 
Registration fee  $25 
Total Due