2016-2017 registration form.doc


Registration Form

Student Name: _________________________________ Age:_______  Birthday: _______________

Parent / Guardian: ___________________________________________________________________

Home Phone: ______________Mothers Work: _____________ Fathers Work: _________________

Mother’s Cell _______________ Father’s Cell  ______________Student’s Cell ________________

Address:  ____________________________________________________________________________

City: ____________________________________________ Zip Code :__________________________

Parent E-Mail: _____________________________ Student’s E-Mail __________________________

Prior Experience: ______________________________________________________________________________

Interested in Performing in Fiesta 2017? Yes ___No ___ 3 or less shows/day___ 3 or more___

Emergency Contact: _______________________________________ ________________________

Address: ____________________________________________________________________________

Home Phone:  __________________ Work:___________________ Cell Phone: ________________

Relationship to student: ___________________________________________

Please read and initial below where indicated

________ I understand tuition is due by the 1st of each month with a grace period until the 10th.  

               All payments received AFTER 7PM on the 10th are considered late, and a $25 fee will

               be added to account

________ I understand there will be a service fee of $25.00 for any returned checks.

________ I understand there are extra fees/deposits associated with Fiesta called

               “Fiesta/Contract fees” These fees are broken up per month starting in January.  If

                 any of these payments are late, a $25 late fee will be added to account

The undersigned hereby agrees to defend, indemnify, and hold harmless the Linda Vega Dance Studio and it’s instructors and agents from any and all loss, damage, liability, charges and expenses and causes of action of whatever character which may arise by reason of attending classes and/or participating in any studio event.

Signature: __________________________________  Date: ______________________

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Office Use Only

Date Received: ________________

Check # ___________ Amount ____________

Class(s) _____________________     _______________________    ______________________



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