Registration Form

Student Name_________________________________________________Birthdate___________________

Address________________________________________________________________________________

City___________________________________________Zipcode________________

Mother's Name_______________________Father's Name_____________________

Home Phone_________________________Work Phone_______________________

Any medical problems?__________________________________________________
____________________________________________________________________

(I understand that On Your Toes Dance Studio and its staff will assume no
responsibility for injuries or medical expenses incurred by my child. My
child has no physical, mental or emotional condition which would interfere
with participation in this program.)

Parent/Guardian Signature________________________________________ Date____________________

Class Tuition______________________

Registration Fee: $10.00      [Your fee is waived if a new friend/relative enrolls for semester I   11/12]  

Total_____________________

*There is a  $25  fee for returned checks

Requested Class ___________________ Day_________ Time_________