2011-2012 REGISTRATION FORM

STUDENT INFORMATION

First Name*

Last Name*

Date of Birth*

Cell Phone

School attending

Grade

Dance/Music or related experience

PARENT(S) INFORMATION

Mother's Name

Father's Name

Mother Cell Phone

Father Cell Phone

Home Phone*

Street Address

City

Zip Code

E-Mail address*

Other Family Members enrolled

Emergency Contact/phone

DANCE CLASS(ES) Dance For Joy!

List the class(es) you want to enroll in. Be sure to list choice of day if more than one is available, and if you are enrolling in optional add-on choices, such as Acro, Pointe or Lyrical.

DANCE CLASS SELECTION

Dance Class Payment Plan

MUSIC LESSON(S) Make a Joyful Noise!

List the music lesson(s) you want to enroll in. List preferred day/time and teacher if you have a preferrence. Music lessons are one on one and will be scheduled where time slots are available. All music lessons are charged monthly based upon the number of weeks in the month.

MUSIC LESSON SELECTION

PAYMENT METHOD

Checks and Online Banking payments should be sent to The Studio of Dance and Music, 7313 International Place, Suite 100, Sarasota, FL 34240; Credit Card payment information is found below.

Payment method*

Credit Card payments: plese fill in these boxes

There is a $2.50 convience fee add to your charge. If you selected Automatic Charge above, your tuition will be charged automatically on the due date.

Card Number

Expiration Date (MM/YY)

Name as appears on the card

Billing Street Number and Street address

Billing Zip Code

How did you hear about the Studio of Dance and Music?

Choose a box, and offer more information if you desire. If referred by a friend, please tell us who so we can acknowledge them.

Newspaper Phone Book Studio Website Internet Search Drive By "Word of Mouth" Referred by a Friend

Other/More specifics

ACKNOWLEDGEMENT AND PERMISSION TO DANCE

By typing my name below; I acknowledge that I have read the Terms of Enrollment, read The Withdrawal and Refund Policy, authorize the named student to enroll and guarantee all payments to The Studio of Dance and Music.

Date of Registration*