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)__________

City Dance Policies

______I have read and agree to the City Dance Policies.

Print Name:_________________________________

Signature:_______________________________________                Date: ______/______/_________