EASTON DANCE ACADEMY

REGISTRATION FORM

2010-2011

Parent or Adult Responsible for Student: ______________________________________

Address: ________________________________ City/State/Zip: ________________________

Home Phone: ___________________ Work Phone: __________________

E-mail:________________________________________________________________

Emergency Contact: ___________________Relationship:___________________
Phone: __________________

Student Name: __________________________________ Birthdate: ___________ Age: ____

Medical Information: List any allergies or medical conditions which teachers should be aware of: ___________________________________________________________________

Class Information:

Date of Enrollment: _________________

There is a additional registration fee of $25 per student which is non-refundable. This reserves placement in Easton Dance Academy.

New Student    Returning Student       Previous training_____________________

CLASSES ENROLLLING IN:

DAY:  ____________TIME: ____________CLASS: ____________

DAY:  ____________TIME: ____________CLASS: ____________
TOTAL TUITION________________(Including $25 registration fee)

TOTAL PAID__________________  BALANCE DUE_________________
Please use the back for additional classes

Studio Policies (Please read and initial each line)

___After 1 month of registration, class enrollment can no longer be changed.

___After this time there are no refunds or credits.

___Once a student is signed up for a class, he/she is responsible for the full year’s payment, as we hold a place for the student for the entire year.

___Dress Code: A mandatory dress code will be enforced by the teacher.

___Tardiness: All students are expected to be on time for class. Students more than ten minutes late will not be allowed to participate in class.

___Any returned checks will be charged a $25 fee.

Release from Liability: I do hereby Easton Dance Academy and its staff from liability occurring on or around the studio premises, or any function held at other locations in connection with dance classes in which student(s) named above is/are enrolled. I declare that the student(s) named above is/are in good health and can participate in dance education classes. Given the nature of dance classes, and with the knowledge that injuries sometimes might occur, I have taken the necessary steps to obtain accident, health, or hospitalization insurance which would cover any sustained injury. In the event of an injury or emergency when I cannot be contacted, I give my permission for you to obtain medical services for the student(s) named above.

Signature: _________________________________ Date: _____________