Registration Form

Student Name ___________________________________________Birth Date_______________________

Address_________________________________________________________________________________

City_______________________________________State____________________ Zip__________________

Child’s Date of Birth___________ 
 

            Mother/Guardian Information:                                       Father/Guardian Information:

            Name:_____________________                                       Name:_____________________

            Phones: Home (     )________________________           Phones: Home (     )________________________

                           Cell (     )________________________                                Cell (     )________________________

                          Work (     )________________________                              Work (     )________________________

                          Email_______________________________      Email____________________________________

Emergency Information:

Health Conditions: ________________________________ (Asthma, High Blood Pressure, etc...)

Emergency Contact: _______________________________ Relation to Child: ______________________

Emergency Contact Phone (     ) ______________________

Doctor Name: ___________________________________     Doctor Phone (     )______________________

Health Insurance Provider: _________________________  Insurance Policy#:______________________

Hospital Preference:_______________________________

Please enroll me/my child in the following class(es):

1.      ____________________________________________ Day_______________ Time_______________

2.      ____________________________________________ Day_______________ Time _______________

3.      ____________________________________________ Day_______________ Time________________

4.      ____________________________________________ Day_______________ Time________________

5.    ____________________________________________ Day______________  Time________________

6.      ____________________________________________ Day_______________ Time________________

7.      ____________________________________________ Day_______________ Time________________

8.      ____________________________________________ Day_______________ Time________________

Type of Enrollment (Please indicate one): Monthly______ Single Class_____

I(We) do hereby indemnify United Dance, its administrator and representatives from all claims, losses or expenses which may arise out of or as a result of my (our) participation in the class.  The owners and or lessees of the premises where this class is conducted shall also be held free from and claim of personal loss injury.

I understand that tuition is due on the first day of the month.  I understand that a $5.00 LATE FEE will be charged on any payments received 2 weeks after payment is due.  I understand that a $16.00 RETURNED CHECK charge will be assessed for any returned checks.  I also understand that there will be NO REFUNDS for classes missed unless a Doctor's written orders are presented.
 

A registration fee of $11.00 per year per individual is due the first week of September or at any later date that a student enrolls with United Dance. Paid Date: _________________ Account Code:_______________

Signature (Parent/Guardian if under 18) ________________________________________________________