DANCE REGISTRATION Parent/Guardian Email Dancer Name: * First Name Last Name Gender * Girl Boy Date of Birth: * Ex: Format as follows: (mm/dd/yyyy - 10/02/1998) Age: * Please select the age group that applies to the student: 18mth-2 yrs. old 3-4 yrs. old 5-6 yrs. old 7-9 yrs. old 10-14 yrs. old 15-17 yrs. old 18yrs -up Dance Classes: * Which Dance Program is your child interested in? We specialize in teaching Ballet, Jazz, Creative Movement, Hip Hop, African, Lyrical, Modern Dance, and Liturgical) Pretty In Pink (18mth-2yrs old - Pre-Ballet, Creative Movements) Petite Daisy (3-4 yrs. old -Ballet, Jazz, Creative Movement) Petite Violets (3-4 yrs. old - Ballet, Jazz) Petite Bloom (3-4 yrs. old - Ballet, Tap) Petite Lillies (3-4 yrs. old - Ballet, Tap) Sparkles (5-6 yrs old - Ballet, Jazz, Lyrical)) Sunflowers (5-6 yrs old - Ballet, Jazz. Creative Movement, Hip Hop, African) Arabesque (5-7 yrs old - Ballet, Tap Regin (7-9 yrs old - Ballet, Tap) Halah (7-8yrs old - Ballet, Jazz, Lyrical) Elevation (8-10 yrs old - Lyrical, Jazz) "Leap" Premier (8-12 yrs old - Ballet, Jazz, Lyrical, African) " Elite" Premier (8-12yrs - Ballet, Jazz, Hip Hop, Lyrical, African) "Rise" Destiny 1 (Middle/High School- (Lyrical/ Jazz) "Rise" Destiny 2 - (Midde/High School- (Majorette/ Hip Hop ) Adult Dance Class Payment Information: * Credit Card Issued As: Visa Mastercard Discover American Express Dance Registration Fee: * Returning Student = $30 New Student = $45 (2 or more) Students = $60 $30.00 $45.00 $60.00 Credit Card Number: * Card Expiration Date: * Ex: (Month/Year - 04/20) Full Name on Card: * (Please provide the name as it appears on card*) First Name Last Name Card Nickname: Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Contact Number: * (###) ### #### How did your hear about us? * Referral Friend Family Social Media Other Required Policies & Agreements * Assumption of Risk: The individual signing this agreement assumes all risk associated with the student participating in dance class, rehearsals, and any other studio related activity. Said person assumes responsibility for any ACCIDENTS, INJURY, OR LOSS OF PROPERTY Release of Liability: DESTINY DANCE STUDIO AND INSTRUCTORS ASSOCIATED WITH THE COMPANY ASSUME NO LIABILITY FOR ACCIDENTS, INJURY, OR LOSS OF PROPERTY AND THE SAME SIGNING THE AGREEMENT ON THE BEHALF OF SAID STUDENT ASSUMES RESPONSIBILITY THEREOF. I AUTHORIZE AND AGREE TO ALL MEDICAL ATTENTION NECESSARY FOR MY CHILD IN THE EVENT OF ACCIDENT, INJURY, AND/OR SICKNESS. Payment Policies: I AGREE TO PAY THE TUITION FOR CLASS/PROGRAM SELECTED BY DUE DATE. THERE IS A $10 LATE FEE CHARGE ADDED AFTER THE 10TH OF THE MONTH. TUITION DUE IN EXCESS OF TWO MONTHS MUST BE SUBMITTED IN FULL PRIOR TO FURTHER PARTICIPATION IN CLASS. NO REFUNDS ARE GRANTED FOR CLASSES/PROGRAM NOT ATTENDED. IF A CLASS/PROGRAM IS MISSED DUE TO ILLNESS, A MAKE UP CLASS CAN BE ARRANGED FOR DANCE CLASSES WITH THE FRONT OFFICE STAFF. IF CLASSES ARE POSTPONED DUE TO WEATHER OR OTHER UNAVOIDABLE CIRCUMSTANCES, MAKE UP CLASSES WILL BE ARRANGED. I've read the above terms and I agree in its entirety. Parent\Guardian Signature: * (Please type first & last name to confirm, sign, and agree with above terms*) First Name Last Name Thank you!
