Registration Form

NORTHERN DANCE THEATRE 2010-2011
Dance Registration Form

this form or obtain one at the studio to mail in.
Registration fee, non-refundable, is $30.

Students Name *

Date Student Started Ballet Training *

Class(es): 1) *

2)

3)

Parent(s) Names *

E-mail Address: *
Home Phone # *

Mailing Address *

City, State and Zip Code *

Cell #

Work #

Name of Academic School

Phone # of Academic School

Grade

Birthdate *

Students Age as of 9/1/11 *

Parent Signature / Date *

Allergies

Medical Insurance Company

Policy #

Name of Physician

Physician Phone #

Emergency Contact Person

Relationship

Home Phone #

Work Phone #

* Required

(PLEASE DO NOT WRITE BELOW THIS LINE)

===============================================================
DATE $ OR # PAYMENT TUITION OTHER BALANCE
Sept. 1st __________________________________________________________________
Dec. 1st __________________________________________________________________
March 1st _________________________________________________________________
Costume Rental __________
Photos _____________
DVD _______________
Other ___________________
Summer __________________________________________________________________

Paid in Full: _________________