Sharon DiCrosta, Director

FALL REGISTRATION

Don’t be left out, classes are limited.

PLEASE PRINT AND MAIL THIS FORM ALONG WITH REGISTRATION FEE AS DESCRIBED BELOW.

The Dancer’s Studio Shoreline, Inc. is now accepting registrations for the 2011/2012 season. New classes are forming for students ages 2 and older. Pre-Registrations MUST BE MAILED, and will be numbered as they are received. This registration number will determine the number used for purchasing recital tickets next spring(minimum two ticket purchase per registration number). This application should be read carefully, signed and returned to the studio along with a $20.00 registration fee per student or $30.00 per household. Applications without the proper registration fees will be returned unprocessed.

STUDENT’S NAME:__________________________________AGE:________DOB:________

STREET ADDRESS:____________________________________________________________

CITY:_________________________ZIP CODE:______________HOME PHONE:__________

PARENT’S NAME:__________________WORK PHONE:__________

CELL PHONE:__________________EMAIL:_____________________

EMERGENCY CONTACTS: (please list name, phone and relationship)

1.____________________________________ 2.______________________________________

Please list and explain any medical problems, medications, or history of which the teachers and staff should be aware.

Circle the classes you wish to take: BALLET TAP JAZZ LYRICAL HIP-HOP ACRO

(ages 7& up)

PRE DANCE 1 PRE DANCE 2 PRE DANCE 3 HIPPETY HOPPIN’

(Ballet) (Ballet/Tap) (Ballet/Tap) (Hip Hop)

(age 2-3) (ages 3 1/2-4) (ages 5-6) (ages 5-6)* Pre Dance 3 required*

PRE ACRO

(ages 3 ½-6)

Circle your preference: WEEKDAY SATURDAY

Circle the program you are most interested in: COMPETITIVE RECREATIONAL ADULT

The undersigned agrees that although tuition is payable on a monthly basis, all paid tuition is non-refundable.

PARENT SIGNATURE__________________________________________________________________

FOR OFFICE USE ONLY: REG. #________ DATE REC.:_______ REG. FEE: $_________