Early Registration Form by AM3020p

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									                    GET A HEAD START WITH
                     EARLY REGISTRATION!!

REGISTER NOW FOR OUR FALL 2012 – 2013 SEASON UNTIL
 JUNE 1ST AND RECEIVE $10.00 OFF THE REGISTRATION
               FEE (NORMALLY $25.00)

                          CLASSES INTERESTED IN
                             (PLEASE CIRCLE)

              BALLET * POINTE * JAZZ FUSION
               JAZZ * MODERN * HIP HOP
             TAP * LYRICAL * CONTEMPORARY
           COMBO – (BALLET/JAZZ OR BALLET/TAP)

                      Early Registration Fee Special: $15.00
                         (If received on or before June 1st)

PARENT NAME_______________________________________________________
STUDENT NAME ______________________________________________________
ADDRESS_____________________________________________________________
CITY_________________ STATE_____________ ZIP_______________________
PARENT SOCIAL SECURITY # ____-____-____ (Secured in DanceWorks by Akada Software)
PHONE___________________________ CELL PHONE ______________________
WORK PHONE__________________________STUDENT AGE_______________
YEARS OF TRAINING______________________ BIRTH DATE _____________
DANCE SCHOOLS ATTENDED LAST YEAR_____________________________
ANY MEDICAL CONDITIONS WE SHOULD KNOW ABOUT ______________
IF YES, PLEASE EXPLAIN ____________________________________________
DAYS UNABLE TO ATTEND____________________________________________
HOW DID YOU HEAR ABOUT US?
________________________________________________________________________

E-MAIL ADDRESS________________________________________________

                   (Office Use Only)Registration Fee________________
      Payment Type: Check#_______Cash_______Credit________ Visa / Mastercard

								
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