2011-2012 REGISTRATION FORM STUDENT NAME_______________________________________  STUDENT'S CELL PHONE____________________ DATE OF BIRTH_______________      AGE ____________ SCHOOL ATTENDING_____________________________________________  GRADE__________ EXPERIENCE__________________________________________________________________________________ PARENTS OF MINOR STUDENT MOTHER___________________________________________________  CELL PHONE_____________________ FATHER___________________________________________________  CELL PHONE: ____________________ STREET ADDRESS____________________________________________________________________________ CITY________________________________________________ZIP__________________ HOME PHONE________________ E-MAIL____________________________________ OTHER FAMILY ENROLLED_______________________________________________ EMERGENCY CONTACT IF PARENT CANNOT BE REACHED NAME_________________________________________________________  PHONE_________________________ ENROLL IN THE FOLLOWING DANCE CLASS(ES) or MUSIC LESSON(S) (indicate desired day & time if there is more than one choice offered) 1._________________________  3.__________________________ 2._________________________  4.__________________________ CIRCLE DANCE CLASS PAYMENT PLAN:                   IN FULL          4 PAYMENT PLAN             8 PAYMENT PLAN          MUSIC LESSON PAYMENTS ARE DUE THE FIRST OF EACH MONTH FOR THE NUMBER OF LESSONS IN THAT MONTH. CIRCLE PAYMENT METHOD:                   CASH, CHECK OR CREDIT CARD             POST DATED CHECKS                  ONLINE BANKING         AUTOMATIC CHARGE (forms available in the office) HOW DID YOU HEAR ABOUT The Studio of Dance & Music? Phone Book    Newspaper    Magazine    Drive By    From a friend ________________________________   TheStudioOfDanceandMusic.com    “Word Of Mouth”    Other:__________________ BY SIGNING THIS REGISTRATION FORM, I ACKNOWLEDGE THAT I HAVE READ AND AGREE TO THE 2011-2012 TERMS OF ENROLLMENT AND THE  WITHDRAWAL & REFUND POLICY AND HEREBY AUTHORIZE  THE ABOVE NAMED STUDENT TO ENROLL.  I GUARANTEE ALL PAYMENTS TO THE STUDIO OF DANCE AND MUSIC. ______________               ________________________________________        Date                                Signature (Parent or Adult Student) Dance For Joy!                               Make A Joyful Noise!

If mailing the registration forms, mail to:           The Studio of Dance & Music           7313 International Place, Suite 100           Sarasota, FL  34240   E-mail this form to dancesarasota@aol.com