REGISTRATION FORM (please print)

*$30 per person or $50 per family


Student: T-Shirt Size:



Age: Birth date:


Email Address (for TDC use only):


Address:



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:


Date:


AUTOMATIC PAYMENT CONSENT FORM


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)