City Dance Registration Form
Student Name:_______________________________________
Address:____________________________________ City:_______________________________ Zip_______________
DOB: ______ /_______ /_________ Age:___________ Grade:______________
Home Phone: (______)_________________ Work Phone: (______)_________________ Cell: (_____)_______________
Email Address:____________________________________________
Mother's Name:_______________________________ Father's Name:___________________________
Other Contact (Specify):______________________________________________________________________________________
Mother's Cell/Work(Specify One): (_____)____________________ Father's Cell/Work (Specify One): (_____)_____________________
Doctor's Name:____________________________________ Doctor's Phone #: (_____)___________________
Medical Information or Conditions to be Aware of:__________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Prior Dance Training:__________ Location:______________________________ Number of Years:________
Dance Forms Studied:________________________________________________
How did you hear about City Dance?___________________________________________
Children's Classes:
Pre-School Class (Age 3-5)____________
Ballet and Tap Combo (Age 5-9)__________
Jazz/Hip Hop Combo (Age 10-13) ___________
Ballet/Jazz/Tap Combo (Age 13-17) ____________
Hip-Hop__________
Mother/Daughter Street Funk____________
Pre-Teen, Teen, and Adult Classes:
Tap_________
Jazz_________
Street Funk__________
Ballet__________
Pointe__________
(must have permission to take the pointe class and must be enrolled in ballet class that preceeds.)
*Private classes are available for $60.00/hr. Duets are $50.00/student. Trios are $40.00/student. The student(s) will meet for 15 minutes/week with the instructor. Times are limited and need to be scheduled with Michelle before November.
Payment Plan:
Yearly(with 10% discount if paid by end of October)__________
Half Year_________
Thirds(three equal installments)__________
Monthly(on the first class of each month)__________
______I have read and agree to the City Dance Policies.
Print Name:_________________________________
Signature:_______________________________________ Date: ______/______/_________