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Dance Mechanix School of
Dance Registration Form
Please PRINT the info
requested below and bring or mail it to 69 Glen Echo
Shore Road, Charlton 01507 with payment of
$15.00
for Returning Students
$20.00 for New Students. (maximum
registration fee per family is $35.00) . For further info or to request add'l
forms,
call the studio at 508-248-1007.
Student's
Name___________________________________________Age:____________
Birth Date _____/ _____/_____/
Street Address____________________________________________________________
Town / City___________________________________________________State_______
Zip______________
Home phone__________________________________
Parent's daytime phone_________________________________
Parent's cell________________________Student's cell___________________________
Parent's email_______________________ Student's email_________________________
Please indicate: [ if you require add'l space, please use the back of the form ]
Previous Dance Training [ new students only ]
Where?___________________________________________________________
Years___________
Subjects: Ballet________ Jazz________ Tap________ other________________
Hours per week________
How did you hear about us?_________________________________________________
Name of person responsible for account [ Please Print]
________________________________________________________________________
Address [ if different than student's ]
________________________________________________________________________
Phone [if different than student's]
___________________________________________________________________
There is an inherent risk of accident or injury when
participating in a dance or exercise program. By signing you are indicating that
you recognize this fact and that you waive, release and hold harmless associates
of The Dance Mechanix School of Dance and the Shake Rattle & Roll Program,
and their
heirs, assigns, employees and independent contractors from any
liability for any injury, damage or claim arising from participation in any
program of dance instruction or exercise.
Parent's Signature
______________________________________________________________ Date ___________
•• I have read the general information
sheet and agree to the studio policies located on the website••
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[
Class information below will be
completed by the studio office at time of registration]
SUBJECT / LEVEL______________________________________________________
DAY / TIME / STUDIO___________________________________________________
CLASS HOURS_________________________________________________________
Monthly Tuition________________ Costumes deposits________________________
First tuition payment due _______________
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DANCE
MECHANIX SCHOOL OF DANCE
