REGISTRATION FORM (please print)

*$30 per person or $50 per family

Student: T-Shirt Size:

Age: Birth date:

Email Address (for TDC use only):


City/Town: Zip Code:

Parents Name:

Home Phone #: Cell or Work Phone #:

Emergency Name and Phone # (other than parent above):

How were you referred to us? Current Student Web

Yellow Pages Parade Newspaper

Flyer Referred By Other

Past dance experience (how long and where):

Medical limitations?

Classes registering for:



Student’s Last Name: _____________________Student’s First Name(s): _______________________

Parent’s Name: ________________________________Phone Number: ________________________

I hereby authorize DMBC CORP. dba/The Dance Center to charge my account the amount of

$_______________On date of Registration__________

$_______________On 1st day of each month starting 9/1 & ending 6/1 for tuition

$_______________On 11/1 for Costume Fee

$_______________On 3/1 for Recital T-Shirt $15

$_______________Other on date__________________

~I will give the school office 1 month’s written notice from the first of the month to discontinue these charges. Ex: payment is required on the month my withdrawal form is signed & for the following month.

~I have received a copy of the school policies.

~I will fully comply with the schools requirements.

*Parents Signature or student 18 years or older: Date:

Method of Payment Checking Account (attach voided check) Postdated checks (attach checks)

Routing # Account #

Name as it appears on account (and address if different that student)