Registration Form

Norwalk Academy of Dance
                                        Registration Form            Registration Date                             

Billing Name:                                                                                                                                                             

Address:                                                                      City:                                         State:                Zip:                 

Hm Phone:                                                                   E-mail:                                                                                    

Parent 1:                                                                                  Hm Phone:                                                                 

Employer:                                                                                Work Phone:                                                              

Cell:                                                                

Parent 2:                                                                                  Hm Phone:                                                                  

Employer:                                                                                Work Phone:                                                              

Cell:                                                                

Emergency Contacts:                                                                                       Phone:                                                

                                                                                                                        Phone:                                                

Students Name: (as it should appear in Recital Program)                                                                                           

Address:                                                                      City:                                         State:                Zip:                 

Birth date:                                                        School:                                                            Grade:                         

Important Medical Info:                                                                                                                                  

Dr. Name & Phone:                                                                                                                                                    

(if medical condition listed, please attach doctor’s consent letter)

Classes

Class Name                                                      Level                                       Day                                          Time

                                                                                                                                                Tuition:                      

                                                                                                                                                TOTAL                      

My signature acknowledges that I understand that trimester payments are due at registration, on 12/15 and 3/15 with a costume fee of $65.00 per class due on 11/1.  A late payment fee of $15.00 will result if payments are more than 15 days overdue.  I also understand that Norwalk Academy of Dance is not responsible for personal injury or lost property and release claims of liability for my child(ren) while they study dance on the premises or under the supervision of Norwalk Academy of Dance.  I also understand that the registration fee is non-refundable and that tuition is non-refundable after the second day of class.  I give permission to Norwalk Academy of Dance to use photos of my child in advertising, website promotion, or brochure materials.

*Attendance is an essential part of our program. If a dancer is absent 6 times (per class) with 2 being after May 1^st, the teacher has the right to withdraw the student from the recital dance.

Parent/Guardian Signature:                                                                          Date:                                                  

Checks may be made payable to:
 Norwalk Academy Of Dance