* = required information

Students Name:*  Date of Birth: Age:

Student's shoe size: T-shirt size: YS YM YL AS AM AL

Student's Address:  City:  Zip:

Home phone:*  Cell phone:

E-mail address:*
 

Payment Information

Person responsible for Payment/relationship:*
(MUST BE EMPLOYED OR HAVE SOURCE OF INCOME)

Paying customer's phone#: *

Person responsible for payment's employemnt or source of income: * Work#: *

Address where statements and billing should be sent: *
 

Parent Information

Mothers Name:  * Mother's Employment:

Mother's work phone: * Mother's Cell phone:

Best time to reach AM PM

Fathers Name  Father's Employment:

Father's Work Phone: Father's Cell phone:

Best time to reach AM PM

How did you find out about our studio?

* = required information

Fall 2011/2012 Classes

If you don't see your class listed above, please add here. We will call you with day/time (classes include Clogging, Adult Ballet/Tap/or Jazz, Tap Tricks/ Ballroom)
Class name: Best Days/Times for you:

Does the student have any medical conditions, etc. that we need to be aware of? Explain:

Does the student have any prior experiences in dance or gymnastics?
Indicate where attended, classes taken, and years of training:

Parental Release (Required for students < 18: Must be filled out to complete this registration)
I, * , parent or legal guardian of student, * , agree to release Elite Dance Academy, Inc., it’s staff, instructors, or landlords of any liability related to injury to myself or child related to participation in Elite Dance Academy, Inc. classes, rehearsals, performances, or related programs and events. I also agree to pay, in full, the non-refundable and non-transferable tuition for the registered classes and production cos-tumes as well as an annual registration fee. I understand Elite Dance Academy, Inc. is not responsible for lost or sto-len items. Photos and videos taken during class, rehearsals, and performances may be used by Elite Dance Academy, Inc. for publicity or marketing materials. Video taping of classes/productions by anyone other than staff is not per-missable without express consent of Director. I understand monthly tuition is due by the 5th of each month and that tuition will be due monthly until and unless a 30-day advance written notice of withdrawal signed by the par-ent/guardian is received by the studio (with the exception of contract students). A $15 late fee will be applied to de-linquent accounts. To ensure proper credit to your account, please put student's name on all checks. Tuition is not pro-rated for months with holidays or otherwise missed classes, however, if a class is missed due to a holiday, another class that week may be taken as a make-up of a lesser or equal level.

Parent/Legal Guardian Name: *

PERSON RESPONSIBLE FOR PAYMENT MUST SIGN THIS BEFORE 1ST CLASS:
WITHDRAWAL POLICY FOR CUSTOMERS NOT UNDER CONTRACT: A 30-DAY ADVANCE WRITTEN NOTICE IS RE-QUIRED TO WITHDRAW THE STUDENT, AFTER WHICH YOUR ACCOUNT WILL NOT BE BILLED FOR FUTURE MONTHS. IF A WRITTEN NOTICE IS NOT RECEIVED, YOU WILL BE RESPONSIBLE FOR MONTHLY TUITION FOR THE ENTIRE SEA-SON. FAILURE TO PAY TUITION ON TIME WILL RESULT IN YOUR ACCOUNT BEING TURNED OVER TO COLLECTIONS AND COULD AFFECT YOUR CREDIT. YOU WILL BE RESPONSIBLE FOR COLLECTIONS FEES UP TO AND INCLUDING LEGAL FEES, AS NECESSARY TO COLLECT ON YOUR ACCOUNT.
WORTHLESS CHECKS WILL RESULT IN A $30 RETURNED CHECK FEE. ALL MEANS NECESSARY WILL BE USED TO COLLECT ON WORTHLESS CHECKS THROUGH THE DISTRICT ATTORNEY’S OFFICE.

Person responsible for Payments on this student's account:
Name: * Date: *

* = required information

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