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. This is your agreement for payment on your account and that you have read and understand the studio policies. *
Date *

I have read and agree to the Privacy Policy *

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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.