Summer Registration

Student's Name: __________________________________________ D.O.B. ______________________

Parent's Name: ________________________________________________________________________

Address: _____________________________________________________________________________

City: _______________________________________ State: ___________ Zip: ____________________

Home Phone: _____________________________ Cell Phone: _________________________________

Mother's Work Phone: __________________________________________________________________

Father's Work Phone: __________________________________________________________________

E-Mail: ______________________________________________________________________________

Previous Training and Studio(s): __________________________________________________________

_____________________________________________________________________________________

Please list any physical limitations, if any: _________________________________________________

_____________________________________________________________________________________

Program or curriculum choices:

Creative Dance & Crafts: Monday ______ Wednesday ______ Both Days ______

Combination Ballet & Jazz ______ Beginning Hip-Hop ______ Intermediate Hip-Hop ______

Teen Hip-Hop ______ Open Ballet ______ Open Jazz ______ Open Modern ______

Theater Camp ______ DANCEcamp Session 1 ______ DANCEcamp Session 2 ______

Adult Ballet ______ Adult Jazz ______ Adult Hip-Hop ______

Ballet Arts Summer Course: 1 Week ______ 2 Weeks ______ 3 Weeks ______

Costume Construction ______

Emergency Information:
Who, if a parent is not available, should be notified in the case of an emergency?

Name: ___________________________ Phone: _______________________

Photo Release Authorization: (Please check one of the following)

_____ Yes, I give permission for my child’s/children’s picture(s) to be used by Derry Dance Center. I understand that my child’s name may or may not accompany the photo(s).

_____ No, I do not give permission for my child’s/children’s picture(s) to be used by Derry Dance Center.

Signature: _______________________________ Date: _____________________

Full tuition is due upon registration for all programs except Ballet Arts Summer Course. Prepaid tuition is non-refundable. A non-refundable depost of $100.00 is due when registering for the Ballet Arts Summer Course, with the remainder of tuition due by July 15, 2008. This deposit will be applied to your tuition costs.

You may register by mail or by visiting the Derry Dance Center Offices.
Please make checks payable to: Derry Dance Center

Payment (please check one):

Check ______ Cash ______ Visa ______ MasterCard ______

Card Number ________________________________________ Expiration Date _____________

Total Due $________________________ Amount Enclosed $____________________

RELEASE FROM LIABILITY: I do hereby release Derry Dance Center and anyone employed by Derry Dance Center from any liability occurring on or around the studio premises, or at any function held at other locations in connection with dance classes in which the student(s) named about is/are enrolled.

AUTHORIZATION FOR ENROLLMENT: I authorize Derry Dance Center to enroll the student(s) named on this form in dance classes, and I accept responsibility for the payment of tuition for those classes for which the student(s) is/are registered. A $25.00 charge will be billed to the account for any checks returned to Derry Dance Center. I understand that classes with an enrollment of less than five (5) pupils are subject to cancellation. No credit will be given for missed classes, no exceptions.
I understand that registration fees and pre-paid tuition are non-refundable and that there are no refunds or deductions for classes not attended. I understand that teachers are only responsible for students during class time.

By signing this registration form I am agreeing to all rules and regulations of the Derry Dance Center and do not hold the Derry Dance Center liable for the personal injuries due to the physical activity nor loss of or damage to personal belongings.

Signature: __________________________________________ Date: ___________________________