Printable Registration form

Registration 2012 - 2013

Please fill out completely and return with your family registration fee of $25.00. This is a one time per year per family fee.

It is applicable to all classes your family enrolls in from 7/01/12 through 6/30/13

Registration Fee and Tuition are non-refundable.

Name_________________________________________ Home Telephone #(____) _____ - ______

Address_______________________________________ Town_______________ ZIP___________

Parentsí 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



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.


Parentís Signature________________________________Date_____________200___


Office Use Only:Date_____________ Fee: cash / check Check #___________ Amount___________

Staff Initial___________ Age________ Class____________________Siblings N / Y


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