Jill Chase Dance Studio
Jill Chase - Director National Past President
12 Lucille Drive National First Vice President
Shelton, CT 06484
(203) 929 - 4908
__________________________________________________________________________________
NEW EMAIL ADDRESS: jillchase@att.net OFFICE USE
NEW WEBSITE: www.jillchasedance.com
Account #____Post Marked Date___ AM___ PM ___Date Received__________
Registration fee paid_______ Date Of Check_____ Check #__________
REGISTRATION FORM
2011-2012 SEASON
Students
Name:_________________________________________________________________
Students Date of Birth:______________________________ Age______ Grade(fall 2011)_________
Parents
Name:_______________________________________________________________________
Mailing
Address:________________________________________________________________
City______________________ State____________ Zip Code___________________
Phone (Home):___________________________(Work)________________________________
Cell Phone __________________Email address_____________________________________
Emergency Contact(other than parents):___________________Phone ____________________
List Any Medical
Condition_________________________________________________________
Years of Dance with Miss Jill__________ Any previous dance training______________________
Check desired classes: (State only impossible days and times__________________________)
Ballet_______ Tap_______ Jazz_______ Pointe (Miss Jill will approve)_______
Enclosed Registration Fees: $30 per family________
Preschool Classes–Circle desired class: Tuesday 10:45-11:45 a.m. or 2:00-3:00 p.m.
Preschool Classes will be shortened to 45 minutes if five students or less in class. (same price)
RELEASE OF LIABILITY AND PLEDGE
I, ________________________the parent of guardian of ______________________,
a student of Jill Chase Dance Studio, do hereby release from all liability Jill Chase
Dance Studio and its staff for all injuries sustained during the course of dance or
dance-related study on the physical premises of Jill Chase Dance Studio, 12 Lucille
Drive, Shelton, CT. I further understand that tuition is non-refundable and make-up
classes are available upon request. There are also no refunds on costumes. All
returned bank checks will incur a $30.00 charge. Monthly tuition fees are due on the
first of each month; on the fifteenth of each month a $10.00 late fee will be added to
all accounts with a current balance. (example: tuition, costume, competition, Kidspirit, props)
Parent//Guardian Signature ______________________________________________________
Date________________________