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REGISTRATION FEE $25.00

* Required fields
Name *
E-mail Address *
Birthdate *
Age *
Street Address *
City *
State
Zip Code
Home Phone Number *
School Attending *
Grade *
Mother's Name/Contact Numbers
Father's Name/Contact Numbers
Siblings at The Dance Studio (Names & Ages)
Name of Person Responsible for Payment on Account *
	I/we, on behalf of myself/ourselves and my/our minor child hereby release The Dance Studio, Inc., it’s officers, agents and employees and Northwestern College, from all claims for injury which may be sustained by my/our child while participating in dance classes, rehearsals, performances or other dance related activities.
Type Full Name for Signature (Please read and check the information above) This is your agreement. *
Date *

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Please note:

$25.oo Registration Fee Due/$40.oo per family.
After filling out the registration form it will not automatically take you to the payment page.