| *Date
you wish to begin? |
|
| *Billing
Name/Parent (First and Last Name) |
|
| *Address |
|
| *City
and Zip |
|
| *Home
and Cell Number |
|
| *Email
Address |
|
| *Dancers
Name |
|
| *D/O/B |
|
| *Age |
|
| *Years
of Dance Training |
|
| *Medical
History |
|
| *Classes
you are inquiring? (day & time): |
|
| *Medical
release form is with MA Dance or in the mail? |
Yes
No |
| *Yes,
I Understand/No, I Don't Understand that this form is not valid without
payment |
Yes
No |
| *I
have mailed in my payment |
Yes
No |
| *Yes/No
- I stopped by the studio and paid |
Yes
No |
| Please put this amount
on my credit card: |
|
| Visa or Mastercard |
|
| Expiration Date |
|
| Emergency Contacts |
|
| Today's Date |
|
|
|
