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Summer_Registration by dandanhuanghuang


									Artistic Sole Dance Academy
Mailing Address: 11794 Riverview Rd Hanover, MN 55341
Studio Mobile: 612-749-0336 / 612-369-1214

                                                        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
* 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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