Dorothy’s School Of Dance, Inc.
2815 Merrick Road
Bellmore, NY 11710
(516) 783-6734
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2009/2010 REGISTRATION FORM
Student’s Name:_______________________________________________________________________
Address:_________________________________________________________________________
Town:_______________________________________________Zip:_________________________
Home Phone:___________________________ Date of Birth:__________________________
Parent’s Name:_________________________Parent’s Cell Phone:________________________
Parent’s E-Mail Address:____________________________________________________________________
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If you are a new student, how did you hear about us?__________________________________
Previous Dance Training:____________________ Where:____________________________
PLEASE LIST ANY AND ALL MEDICAL CONDITIONS CONCERNING THE STUDENT
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 2009/2010 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 5/1/10). 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______________________________________
Credit Card Authorization Form
Student(s) Name______________________________________
Name as it appears on Credit Card________________________
I have read and understand the 2009-2010 brochure. I have a choice of paying by cash, check, or credit card. However, if tuition is not paid by the 15th 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______________________________
______________ sign here if you would like us to automatically bill your card the first of each month.
