Premiere Dance of Flemington

Registration Form and Student Profile

(For recreational and technique classes only)   

                                                  Please print and fill out a separate form for each student                             Date: _______

________________________          _________________                  _____            ________          __________

Student's Last Name                           First Name                                  Age                  D.O.B.             Years at Premiere

                                                                                                                                                            (Including this yr)

Address: _____________________________           City: __________________             State: __________              Zip: ____________

Home Phone: _________________________             Cell Phone: ____________________            Other: _________________________

*Email Address: _________________________________________________            Mother's Name _____________________________

Allergies: ______________________________________________________            Father's Name  ______________________________

*We’re Going Green! By putting your email address you agree to receive information via E-Mail from Premiere Dance of Flemington.                                                                                      

Please mark classes preferred according to our current schedule. Instructors will advise final placement levels.

                        Current schedule can be viewed at www.premieredanceofflemington.com

                                                                                   Receipt #                                               Date       

Registration Fee:

One student          $35.00                                      _________                                          ________

Two or more          $50.00                                     _________                                           ________

Tuition Payment Plans:

1. One Time - Annual                                          _________                                           _________

2. Installment Plan

    1st pmt. due at registration                              _________                                           _________

    2nd pmt. due Nov. 15th                                   _________                                           _________

    3rd pmt. due Feb. 15th                                     _________                                           _________

3. Monthly Payments                                          _________                                           _________

 I hereby authorize Premiere Dance to charge my:   ____ Visa    ____ MasterCard    ____ Checking Account.

Account number____________________________________________            Exp ____________________

For my monthly dues which are $___________. I agree that the monthly dues will be charged to my account on or around the 15th day of the month. (Please attach a voided check if paying by checking account).  I understand a cancellation form must be filled out and given to the receptionist by the 10th of the preceding month in which classes are dropped. I understand there will be 9 ½ billings from August to May.  There will be a $10 fee for any direct billing returned from the bank.

I understand that Premiere Dance is not liable for any loss of belongings or for any injury that may occur. I also understand that any class cancellation due to an act of nature will not be made up. All images taken of dance students are the property of Premiere Dance and may be used for promotional purposes, unless a written denial of consent letter is given along with this registration form.

                                                                                                                        __________________________

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