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Fall 2011–2012 Registration Form

To register online, please fill this form out completely. Your credit card will not be charged until you hit the “Submit Registration” button on the last screen.

If you would rather fill out a paper form and bring it in or mail it to us, Click HERE to print out a pdf version of this form.

DANCER’S INFO
Dancer's Name First:   Last: 
Date of Birth (mo/day/yr) / /
Address (incl. apt. #)
City   State   Zip
Family E-mail address
PARENTS’ INFO
Required if dancer is under 18 and/or still living at home.
Mom's Name First:   Last: 
Mom's Phone Numbers Home:   Work:   Cell:
Dad's Name First:   Last: 
Dad's Phone Numbers Home:   Work:   Cell:
EMERGENCY INFO
This information is used in the event that we CANNOT reach a parent.
Emergency Contact Name First:   Last: 
Emergency Contact Phone
Relationship to Dancer
Doctor’s Name First:   Last: 
Doctor’s Phone
CREDIT CARD INFO
Please autocharge my session/installment fees on due dates throughout the season.
Please charge registration fee & first session/installment fee ONLY — I will pay directly or charge by phone the remaining payments.
Card Type
Card Number
Name on Card
Expiration Date /
Overdue balances remaining on account over 15 days will automatically be charged to your VISA/MC. If you are unable to provide an active card number, a flat fee of $25 per month will be applied to your account until all new and outstanding debt is satisfied in full.
DISCLAIMER OF LIABILITY

I, on behalf of the parties hereby registered, authorize A Dancer's Dream, Inc. & TAGteach International, LLC the use of the registered party’s image for educational and promotional purposes.  Further, A Dancer’s Dream, Inc., TAGteach International, LLC, their associates & assigns are not liable for personal injuries, loss of or damage to personal property.  Since dance is a physical activity, injuries may occur.  Each student may decline to participate in any activity which may be harmful & is responsible to inform the instructor, in writing, of any physical limitations which may prevent full participation in class or any associated event.

By checking this box, I release all liability and compensation as stated above.
ACCEPTANCE OF POLICIES

By checking this box, I state that I have read and accept the Accounting Fees and Policies, Dress Code, and Keeping You Up-to-Date information. Click the links to read these pages if you have not already done so.

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