North Shore Studio of Dance

StudentRegistration Form 2016-2017 rev 4/21/16

Student’s Name(First & Last):Dateof Birth(if under 18):

Mailing Address:

City/Town:State:Zip:

HomeTelephone # (with area code):

Mother’s Name:Mother’s Cell #:

Father’s Name: Father’s Cell #:

Name of Responsible Party:

Please provide proper email address:

Please advise us of any medical conditions that may affect the student’s participation:

Agreement for Participation

Iunderstand that dance classes may include, without limitation, dancing with props, stretching, barre work, across the floor combinations, dance routines in the center, and other related activities. I further understand that all of the activities of the dance class involve some degree of risk ofstrain or bodily injury. North Shore Studio of Dance is not responsible for personal property.

I have read, understand, and agree to adhere to all the content stated therein including:

*Studio Policies*Tuition & Payment Information*Dress Code*Company Requirements*Calendar

I agree to be responsible for reading studio correspondence and respecting deadlines, if applicable. If paying tuition in full, I understand the discount will be voided if (1) tuition is not completed by the first week of dance classes, (2) costume payments are not completed by 10/15, and (3) competition fees (if any) are not completed by 12/1/16.

 All tuition payments past due are subject to a $25.00 late fee.

I understand that there are no refunds for classes dropped except for Intro to Dance and Creative Combo. Those refunds will only be given until November 1St. Additionally, there are no refunds for sitting out or missing classes due to an injury.

I hereby acknowledge that I have read the statements above and agree to participate accordingly.

Date:Signature:

Credit Card Information

If you would like NSD to keep your credit card number on file and to automatically charge your card as payments are due, please enter all required information. Please be advised that as of 5/1/15 all credit card payments will incur an additional charge of 3% to cover credit card processing fees.

Circle one: Discover MasterCard VisaPrint name on card:

Credit card #: Expiration date: 3 digit code:

Zip code: House number: Signature of card holder:

Please list the class(es) you wish to enroll in.

Style & Level / Age Group / Day/Time / Tuition Due
1. / $
2. / $
3. / $
4. / $
5. / $

(continue on other side, if necessary)

PAYMENT SCHEDULE: DUE AT REGISTRATION- TUITION $ + REG $25.00 PER child= $ DUE 9/1/16$

COSTUME(S): DUE 10/15/16 $ TUITION: DUE 11/30/16 $ DUE 2/29/17 $

Monthly payment options are available! Cards must be kept on file. Payment is the 1st of every month beginning with registration. payments will end May 1, 2016.