DANCE CENT ER

SUMMER 2016 REGISTRATION FORM

Student Name
Date of Birth
Current Age
Parent/ Bill Payer Name
Street Address
City, State, Zip
Primary Phone
Primary Email
Emergency Contact (other than
parent)
Phone
Relation to student
siblings who also attend MDC
MEDICAL INFO
Is the student allergic to any
medications/ foods? If YES, please
list.

Does the student take any kind of

medication on a regular basis? If
YES, please list.

Does the student have health

insurance? If YES, please list
insurance company.

MEDICAL RELEASE: I give permission for my childs medical condition above to be release to my
childs teacher(s). INITIAL_____
PHOTO RELEASE: I give permission for my childs photo to be used in any electronic or printed ad
for Momentum Dance Center. INITIAL_____
NON-REFUNDABLE FEES: I understand that all registration fees and tuition for summer 2016
classes and camps are non-refundable with the exception of business relocation or for medical reasons,
in which documentation is required. INITIAL_____

PARENT SIGNATURE:______________________________ DATE:_____________

PRINT: _______________________________________
OVER

Please list previous dance

experience.
How did you hear about us?

SUMMER 2016 CLASSES, CAMPS & INTENSIVE

6 WEEK SESSION CLASSES

DAY

TIME

TO BE
COMPLETED
BY OFFICE
CLASS CODE

1
2
3
4
5
6
SUMMER CAMPS

DATES

CAMP CODE

DANCE INTENSIVE

TIME

INT CODE

1
2
3

SUMMER 2016 DUES

FEES
REGISTRATION FEE

6 WEEK SESSION

SUMMER CAMPS
DANCE INTENSIVE

DETAILS
$15 per student
$7.50 for each additional siblings
1 class: $85
2 classes: $165
3 classes: 245
4 classes: $325
5 classes: $410
unlimited rate: $500
$135 per student per camp
$275 per student per intensive
TOTAL DUE:

TOTAL

SELECT PAYMENT OPTION:

1. PAY REG. FEE + $35 NON-REFUNDABLE TUITION DEPOSIT TODAY.
(Balance must be paid by first day of class, camp or intensive)
2. PAY IN FULL TODAY.