Dorothy's School Of Dance: 2011-2012 Dance Year Registration Form

Dorothy’s School Of Dance, Inc.

2815 Merrick Road

Bellmore, NY 11710

(516) 783-6734

2011-2012 REGISTRATION FORM

Student’s Name:_________________________________________________________________________

Address:______________________________________________________________________

Town:________________________________ Zip:_________________________________

Student's Grade in school__________________

Home Phone:_________________________________ Date of Birth:______________________

Parent’s Name:____________________Parent’s Cell Phone:_____________________________

Parent’s E-Mail Address:__________________________________________________________

Class # 1	Class #2	Class #3
Class #4	Class #5	Class #6
Class #7	Class #8	Class #9

If you are a new student, how did you hear about us?____________________________________________

Previous Dance Training:_______________________ Where:___________________________________

PLEASE LIST ANY AND ALL MEDICAL CONDITIONS CONCERNING YOUR CHILD(REN)

I have read, understood, and am in agreement with all the information contained in the brochure and give my child(ren), who is (are) in good health, permission to participate in Dorothy’s School of Dance 2011-2012 Program. I also agree to the tuition payment terms listed in the brochure and am responsible for payment (all account must be paid in full no later than 5/15/12). NO REFUNDS. I hold Dorothy’s School of Dance, Inc., and staff harmless for any and all injuries that may arise from participation in any class or other activities related to Dorothy’s School of Dance Inc. In such event, I further agree that the cost of such medical services shall be borne exclusively by myself. I hereby authorize Dorothy’s School of Dance, Inc., to take any steps necessary to make medical attention available, including physicians, hospitals, or any other medical services, and the School shall have full discretion. Photographs and videos of students from the school may be used for publicity in the future.

Signature of Parent/Guardian____________________________________Date______________________

Print Name of Parent/Guardian______________________________________________________

Office use only: Reg. fee______________ Installment 1______________ Installment 10_______________

Total Due______________ Total Paid_____________ Date__________ CA CK CC _______________

________________________________________________________________

Credit Card Authorization Form

Student(s) Name______________________________________

Name as it appears on Credit Card_________________________________

I have read and understand the 2011-2012 DSD brochure. I have a choice of paying by cash, check, or credit card. However, if tuition is not paid by the 15^th of every month I hear by authorize my credit card to be charged for that month’s tuition. I will not incur a late fee unless the card is declined. I will then have to update the credit card information to keep it current and pay the $10.00 late fee.

Credit Card Number__________________________________

Credit Card Type ____________Expiration Date ___________

CVS Code__________

Billing Address____________________________________

Town_____________________ Zip Code_________________

Signature of Card Holder______________________________

For your convenience, you may sign below and have your monthly tuition automatically paid through your credit card. It must be signed below for this to be activated AND a new form for each dance year for security reasons. We keep this document secured for your safety and we shred this document at the end of the 2012 dance year.

_______________________ sign here if you would like us to automatically bill your card the first of each month.