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PART I: STUDENT INFORMATION

Date of Birth

School

Female/Male

Grade

Age

Pertinent Medical Information

Class Requested

Day

Time

Class Requested

Day

Time

Class Requested

Day

Time

PART II: Student/PARENT/GUARDIAN INFORMATION Please complete both columns for any information that differs. Please check the box to indicate the Primary Contact. The Primary Contact is the person responsible for payment of this account. All communications including monthly statements will be sent to the Primary Contact. *

Student
Parent/Gaurdian

Student

Parent/Gaurdian

Adress

City, ST Zip

Home Phone

Cell Phone

Work Phone

PART III: 2018-2019 POLICIES Please read the following carefully. Students will not be permitted to take class until completed. Liability Release and Studio Policies lines must be initialed. Photo Release and Email Permission may be initialed or declined.

Studio Policies and Tuition: I have read the Downtown Dance Center Policies and agree to abide by them. I understand that there are three ways to pay tuition. IN FULL, TWO EQUAL PAYMENTS, or TEN MONTHLY PAYMENTS.
Liability Release: While Downtown Dance Center, its owners, and employees, will maintain proper safeguards at all time, I realize that my child will be actively involved in vigorous, physical activities while in class. Downtown Dance Center makes no representations, either expressed or implied, regarding the physical capabilities of a student, although activities are planned to meet the overall requirements of each group or class. I will not hold Downtown Dance Center responsible for accidents or injuries resulting from normal class activities or student negligence.
Photo Release: I authorize Downtown Dance Center to use photographs or video of students listed on page one for promotional and publicity purposes only. Images will not be used for any other purpose.
Email Permission: I authorize Downtown Dance Center to send my monthly e-newsletters and e-statements to the Primary Contact at the email address listed below. Email will replace my regular postal mailings. I will update Downtown Dance Center of any changes to my e-mail address.

Emergency Contacts: Whom should we contact in the event of an emergency during class?

Phone Number

Relationship

Name

Phone

Relationship

One-Time, Annual Registration Fee: $25.00 for each student; $35.00 maximum for per immediate family. Registration Fee is due at time of enrollment. We accept credit cards, checks, cash and online payments. Please make checks payable to: Downtown Dance Center. PAYMENT OPTIONS: (Please review Tuition Payment Plan Polices) *

I wish to pay IN FULL for the Entire Season (5% discount if paid in full before student starts classes - There are no refunds, transfers or credits given for early withdrawals.)
I wish to pay in 2 EQUAL PAYMENTS (First payment due before the first class. Second payment due January 15th. Select this method and take advantage of a 5% discount for each payment. Minimum of two classes. There are no refunds, transfers or credits given for early withdrawals.)
I wish to pay MONTHLY - Installments are based on the Annual Tuition divided into 10 equal payments. All payments are due the first of every month from September through June. Statements are sent to the email address you provided and include a link to the online payment portal. The registration fee and first tuition payment are due upon registration and is not refundable. Registration will not be complete until the first month’s tuition is paid in full.

PART V: I AGREE TO THE TERMS AND CONDITIONS AS STATED IN THE REGISTRATION FORM

Date

HOW DID YOU HEAR ABOUT US?

Message

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