VIEWS: 2 PAGES: 2 POSTED ON: 12/7/2011
Artistic Sole Dance Academy Mailing Address: 11794 Riverview Rd Hanover, MN 55341 Studio Mobile: 612-749-0336 / 612-369-1214 ArtisticSoleDA@gmail.com Website: www.artisticsoledance.com Summer Registration 1) Student Information Student Name: ____________________________________________________________________________ Age: ____________ Street Address: ____________________________________________________________________________ City:___________________________________ State: _______________ Zip Code: __________________ Date of Birth: __________________ Years of Dance Experience: _________ When and Where: __________________________ 2) Parent/Guardian Information Parent/Guardian Name: _____________________________________Relationship: _____________________ Home Phone: ___________________ Work Phone: __________________ Cell Phone: ________________ E-mail Address: ___________________________________________________________________________ 3) Emergency Information Emergency Contact: _______________________________________________ Relationship: ______________________________ Home Phone: ___________________ Work Phone: __________________ Cell Phone: ________________ Primary Clinic: _____________________________Doctor: ___________________ Phone: _____________________ Medical Issues, Allergies, or Health Concerns: ___________________________________________________________________________________________________________ Optional Pick-up Contact Name: ___________________________________________________Relationship________________________ Home Phone: ________________________ Cell Phone: _________________________________ 4) Enrollment Information Class Selection Day Time 5) Student Release & Consent As parent(s)/legal guardian(s) of the above dancer I hereby release all persons affiliated with Artistic Sole Dance Academy, from any and all claims for damages or injuries that may be sustained during any and all participation in activities connected with Artistic Sole Dance Academy INC. By signing this form I waive the right to any legal action for any injuries that may happen at Artistic Sole Dance Academy INC. Furthermore I certify that the above dancer is in excellent health physically, mentally and emotionally. Also, I give Artistic Sole Dance Academy INC. the right to use any dance pictures or videos taken throughout the year for promotional/educational use. By signing this form I agree to adhere to all policies of Artistic Sole Dance Academy INC. and take full responsibility for all monetary fees. Parent/Guardian Signature: ______________________________________________ Date: _______________ 6) Payment Information Registration Fee $5.00 Class Fees $5.00 Payment Method: Credit Card (Complete account holder information below) Check Cash * There is a $10.00 minimum for all credit card payments. There is also a $0.75 transaction fee per charge for credit card processing. * We do not accept American Express Cards Cardholder Name: __________________________________________________________________________ Registered Address for the Credit Card: ______________________________________________________City ___________________ State_______ Zip_____________ Card Type: ___________ Card Number: _______________________________ Exp. Date: ______________ Cardholder Signature: ______________________________________________ Date: __________________ Office Use Only: Registration received by: _________________ Date: ____________ Method: __________ Class Placement: Day: __________________ Time: _________________ Teacher: ____________________ To secure placement in the class of your choice, send this registration form and registration fee to the mailing address on the front of this form.
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