| Contacts:
Please complete the information below. |
Mother's
Name: _______________________________________ |
Father's
Name: _______________________________________ |
| Address:
_____________________________________________ |
Hm
Phone: ___________________________________________ |
| Mother's
Cell: _________________________________________ |
Father's
Cell: _________________________________________ |
| Mother's
Work: ________________________________________ |
Father's
Work: ________________________________________ |
| Email
The studio uses 2 main forms of communication, email and the
studio website. It is very important that you provide us with
an email address that you check often. If your email address
changes, please provide us with the new one. IMPORTANT: We
do not mail invoices. They are sent by email each month. |
Email
#1 : ______________________________________________________________________________________________________ |
| Email
#2 : ______________________________________________________________________________________________________ |
| Payments
Select method of payment. IMPORTANT: If you decide to withdraw
for any reason, you must complete a withdrawal form and return
it to the studio by the first of the month. This will prevent
an additional monthly tuition charge and possible late fee.
All accounts must have a credit card on file. Provide the
information below. Any account not paid in any way by the
15th, the credit card on file will be charged, plus a $10
late fee. |
____
|
Monthly
Auto Pay |
Registration
fee due at enrollment. Monthly tuition charged the first day
of the month. To enroll for Auto Pay, please include your
credit card information below. |
| Visa/MC/Discover
# ______________________________________________________________________Exp.
Date _______________ |
____
|
Monthly
Manual Pay |
Registration
fee and first months tuition due at enrollment. Monthly tuition
due the 1st of each month, August - May. Accounts not paid
by the 5th, will be charged a $10 late fee. |
____
|
Annual |
Registration
fee due at enrollment. Full years tuition minus 10% is due
on the first class. |
Waiver
of Liability Statement & Permission for Treatment I, the
undersigned parent or legal guardian of the student(s) herein,
do hereby give permission for the aforementioned student(s)
to participate in any and all classes and/or events offered
by or attended by Shannon's Progressions Dance Studio, LLC.
I accept all risks associated with that participation and
understand that there is a full possibility of serious physical
injury or death. I hereby agree not to sue and waive, release
and forever discharge any and all rights and claims for damages,
which may arise now or in the future against Shannon's Progressions
Dance Studio and it’s owners, employees and/or other
assigned representatives or volunteers from any and all liability
and for any and all damages and/or injuries which may be sustained
or suffered by the student(s) listed below and consent to
any other medical procedure deemed necessary in the case of
an emergency. Additionally, I certify that I personally and/or
my medical insurance carrier will be responsible for all expenses
which are incurred in relation to any injury sustained during
any Shannon's Progressions Dance Studio related activity,
including but not limited to classes, competitions, shows,
etc.
Rules & Regulations I have read, understand and will abide
by all general rules that are set forth by Shannon's Progressions
Dance Studio, it’s owners, employees, and directors
and any additional rules or requirements as set forth throughout
the year. A complete copy of rules and regulations are available
at the studio. As primary contact, I agree to make all payments
by their assigned due date. Furthermore, I give my permission
to Shannon's Progressions Dance Studio to use photographs
and/or videos of the student(s) listed above for appropriate
marketing materials.
Costume Charges Students participating in the annual Recital
Showcase will need to purchase one costume per class, at a
cost of $60 per costume. A charge of $20 per costume will
be added to your account for three months beginning with your
September tuition. Costumes will not be ordered for accounts
who have not paid the costume fee each month. Costumes are
ordered at the end of November, therefore a $10 rush ship
charge will be added per costume for orders after November
30th. There will be no costumes ordered after January 31st.
Shannon's Progressions Dance Studio also charges, a Recital
Fee of $20 per family. This helps for the rental of the auditorium.
This will be added to your September invoice. |
| Parent
Signature ___________________________________________________________________________Date
________________ |
Student
Information
Please provide student information below. Remember, we primarily
place students by dance level. The ages listed on the schedule
are to be used as a guide. |
| Student
#1 |
Name:
___________________________________________ |
Date
of Birth: ______________________________________________ |
| School:
__________________________________________ |
Grade
(Fall 2011) ___________________________________________ |
| Medical
Information: ____________________________________________________________________________________________ |
|
| Student
#2 |
Name:
___________________________________________ |
Date
of Birth: ______________________________________________ |
| School:
__________________________________________ |
Grade
(Fall 2011) ___________________________________________ |
| Medical
Information: ____________________________________________________________________________________________ |
|
| Student
#3 |
Name:
___________________________________________ |
Date
of Birth: ______________________________________________ |
| School:
__________________________________________ |
Grade
(Fall 2011) ___________________________________________ |
| Medical
Information: ____________________________________________________________________________________________ |
|
For
Our Records Please tell us how you found out about Shannon's
Progressions Dance Studio |
| Yellow
Pages ___ |
Newspaper
___ |
Mailer
___ |
Road
Sign ___ |
Event
___ |
| Search
Engine ___ |
Referral
/ Who? ______________________ |
Drive
By: ___ |
Other
________ |
For
Office Use Only |
| Date
Registered ___/___/___ |
Registered
By: ___________________ |
Amount
Due $__________ |
Amount
Paid $_____ |
Payment
Type: |
Cash |
Check
# |
MC
/ VISA / Discover (Confirmation #) _______________________ |
|
