| ASTORIA
DANCE CENTRE REGISTRATION FORM Today’s Date: New Student Returning -- Student Age: Birth Date & Year Student's Last Name & First Parent/Guardian Name (if under 21) Mailing Address: Include Apt. Number or Floor City State Zip Home Phone Emergency Number Email address required Years COMPLETED at ADC (do not include Sept. 07-June 08 year) Elsewhere Please list here any medical conditions or disabilities we should know about: How did you find out about ADC? Non-refundable registration fee $35.00 per student $50.00 per family Amount Enclosed I understand and agree to pay my tuition installments by AUTOPAY either from my checking account or credit card. I understand that if I have to stop lessons I must give one month's notice in writing. Once the letter is received I understand that at that time all tuition charges will no longer be charged to my checking account or credit card. If I decide to participate in the year end performances I agree to make my costume payment on or before the due date. I understand that if my costume payment is late that I will pay the $10.00 late fee. I also agree to approve the size of my child's costume size at the time she/he is measured. I agree that if the costume does not fit that I will pay the $10.00 per costume exchange fee. I have also read all the studio policies and I understand the following insurance waiver for myself and my child(ren). I understand that Astoria Dance Centre, its employees and staff will be held harmless from any liability or claims resulting from my child's or my participation in this program. I assume all risks in the event of accident or injury to property or person(s) resulting in any activity. I also understand and I will not hold Astoria Dance Centre responsible for loss of personal items. I am aware that Astoria Dance Centre may take photographs of its dancers for use in promotion of the studio. If I disagree with this, I have attached a letter stating so to this registration form. By signing below I agree to follow all of the above conditions and those included in the studio guideline handout. Signature of Parent /Guardian if student is under 21 years of age required: Signature ____________________________________ Date ___________________ |