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Name of Student:
_________________________________ Age: ______ DOB: ________
Address: _________________________________________________________________
__________________________________________________________________
Home phone: __________________________
Parent work phone: _____________________
Mother's Name: _______________________ Father's Name: ___________________
Sex: F M How many years of dance experience? __________________
Please list the classes in which the above student is to be enrolled
in:
DAY TIME CLASS
1. _______________________________________________________
2. _______________________________________________________
3. _______________________________________________________
I, _______________ agree to pay $ _______ /month to For A Dancer,
Inc. for the above class(es) in which my child or myself is enrolled. I understand that For A Dancer, Inc. and its staff, are not responsible for lost or stolen items, as well as, any injury that may occur on or in its facility. I agree to the payment terms and understand that there will be an additional $20.00 late fee charged if payment is received later than the due date. I give my permission to For A Dancer, Inc. and any member of its staff to call an ambulance in case of a dire emergency that cannot wait for a parent, guardian, or emergency contact to be notified. In the event of such an emergency, the parent will be notified immediately after the ambulance has been contacted. I have read and understand the studio policies and agree to abide by them.
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_________________ |
| Signature of parent |
Date |
Emergency contact & number:_________________________________
Doctor & number: _________________________________________
Allergies/medical problems/medications taken:
_______________________________________________________
School: _______________________ Grade: __________________
E-mail: _________________________________
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