From the day of registration, a student is automatically enrolled for the entire school year. You may register through the mail; however we recommend all students register in person so that you can conveniently purchase your dancewear at the same time. You may come in and register during our summer office hours (please call to obtain varying weekly hours) or come in during one of our Open Houses.
Please carefully fill out the form below. If you are not registering in person, please mail the signed registration form, registration fee ($20.00 per family), and September's tuition payment to:
Mother's Name: ______________________________ Father's Name: ____________________________
Address: _____________________________________________________________________________
City: _______________________________________ State: ___________ Zip: ____________________
Home Phone: _____________________________ Cell Phone: _________________________________
Mother's Work Phone: __________________________________________________________________
Father's Work Phone: __________________________________________________________________
E-Mail: ______________________________________________________________________________
Student's Name: ___________________________________ D.O.B.: ____________________
Student's Name: ___________________________________ D.O.B.: ____________________
Student's Name: ___________________________________ D.O.B.: ____________________
Previous Training and Studio(s): __________________________________________________________
_____________________________________________________________________________________
Please list any physical limitations, if any: _________________________________________________
_____________________________________________________________________________________
- Student: _________________________
Class: ___________________ Day/Time: ___________________
Class: ___________________ Day/Time: ___________________
Class: ___________________ Day/Time: ___________________
- Student: _________________________
Class: ___________________ Day/Time: ___________________
Class: ___________________ Day/Time: ___________________
Class: ___________________ Day/Time: ___________________
- Student: _________________________
Class: ___________________ Day/Time: ___________________
Class: ___________________ Day/Time: ___________________
Class: ___________________ Day/Time: ___________________
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: _____________________
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. I understand that it is my responsibility to pay the tuition on a monthly basis with a due date of the 1st of the month. If tuition is received by the 9th of the month I am entitled to a $5.00 discount. If tuition is not received by the 15th of the month it will be considered late and a 10% late fee will be charged and/or the student will not be allowed to participate in class until tuition is paid in full. 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 also accept responsibility for payment of all End of Year Performance costume fees for the student(s) enrolled, unless I give the Derry Dance Center written notice by November 1, 2008. I understand that teachers are only responsible for students during class time. I understand that if I do not give written notice of the student’s withdrawal from classes by the 10th of the month I am obligated to pay the next month’s tuition payment.
Registration Fee: $20.00
September Tuition: +_____________
*Total Enclosed: $_____________
*Please call the office to have a monthly tuition rate calculated for you.
Payment: _____Check _____Cash _____Visa _____MasterCard
Credit Card Number: ___________-__________-__________-__________ EXP: _________/_________
[ ] Please automatically charge my tuition to my Credit Card on the first of every month*
[ ] Please automatically charge all costume fees to my Credit Card when they become due*
*Additional paperwork will need to be filled out for all automatic payments*
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: ___________________________