ASTORIA DANCE CENTRE
September 2011-June 2012
MUSIC REGISTRATION FORM/AUTOMATIC PAYMENT/CONSENT FORM
42-16 28 Avenue 2nd Floor, Astoria , NY 11103
Print and mail this form with your registration fee. 
Music New Student Returning Student

Student's Last Name: First Name(s):

M F Student Birth date: Age:

Parent's Name:

Phone #: Cell #:

Mailing Address: City: NY Zipcode:

Email: Years completed at ADC:

Where they heard about us: YP WOM NP PB Post Card Sign Internet

Referral Other

Date Registered: Date Starting Lessons:

Medical Conditions: No Yes

Costume Fee(s): ____________________________________________________________________

I understand and agree to pay my tuition installments by AUTOPAY either from my checking account or credit card. Music lessons require a 2 month minimum of lessons.  This is necessary to give the student a fair chance, allows the instructor to work with the student, and possibly try another instrument if necessary.
I understand that if I have to stop lessons I must give two (2) weeks notice in writing. The withdrawal must be done in person, in writing, with a desk staff member (not a teacher).  Once the drop form is filled out, your scheduled Auto Pay is stopped immediately. Auto Pay schedules are not suspended until written notice is submitted.
I understand that the $35.00 registration fee is non-refundable and that there are no credits or refunds on music lesson fees.
I understand that the make up lesson policy is only if the student is sick and that make ups are limited to 2 times per year.
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..  

Signature ____________________________________ Date ___________________

Signature of Parent /Guardian if student is under 21 years of age required.
________________________________________________________________________________