Please fill out completely and return with your
family registration fee of $25.00. This is a one time per year per
family fee.
Registration Fee and Tuition are non-refundable.
Name_________________________________________ Home
Telephone #(____) _____ - ______
Address_______________________________________
Town_______________ ZIP___________
Parents’ Names_________________________________
Emergency # (______) ______ - ________
Emergency Contact___________________
Physician____________________________ Telephone
#(______) ______ - __________
Birth date _____/_____/_____ Age as of Sept. 1,
2009__________Grade as of Sept. 1 ____
E-Mail Address
_________________________________________________________
Current Student_____ # of yrs dancing with PSPA_____
Current class day & time____________
New Student (No Experience) __________ *New
Student with Experience_________
*New students with experience, please list your
dance background including the names of the schools previously attended,
so that the proper placement can be made. You may use the reverse side if
needed.
Year Attended age(s) Dance Style Name of Previous
School
How did you hear about our studio?
Comments: (Allergies, Learning Disabilities, etc.)
Day preference
*******************************Waiver***********************************
I understand that in enrolling by child/ward in
this program as a student, I do hereby release and not hold responsible the
Pembroke School of Performing Arts or any of its employees, instructors,
agents, and officers from any claims, demands, liability, harm, injury or
damages which may result to the student while enrolled in this school, and
all activities connected herewith. As guardian, I also certify that this
student has under gone a complete physical examination within the past six
months, and is not suffering from any physical conditions or disease which
might increase the risk of injury or accident to themselves or others while
participating in school activities. I further agree that I have or will
obtain accident insurance for this child. I have read this release,
understand its terms and conditions, and execute this of my own free will.
Children's photos may be used in advertising, but names will be withheld.
Student_________________________________________________________________
Parent’s
Signature________________________________Date_____________200___
_________________________________________________________________________________________________________________________________________
Office Use Only:Date_____________ Fee: cash /
check Check #___________ Amount___________
Staff Initial___________ Age________
Class____________________Siblings N / Y