ASTORIA DANCE CENTRE
DANCE REGISTRATION FORM/AUTOMATIC PAYMENT CONSENT FORM
42-16 28 Avenue 2nd Floor, Astoria , NY 11103

Print and mail this form with your registration fee. 
Dance Acting Broadway Bound
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:

Class(es)

Medical Conditions: No Yes. If yes please describe:

Does your child take any prescription medication regularly? No Yes
If yes please describe:

Are there any learning and/or behavioral conditions that Astoria Dance Centre should know about?
This information helps us to best serve your child's needs No Yes
If yes, please describe.

Costume Fee(s):
______________________________________
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I understand and authorize Astoria Dance Centre to automatically charge my credit card for tuition and for the November 10th costume fee(s).  I understand that if my credit card does not process on the 10th of the month that my payment must be paid by cash or check at the front desk.

I also understand that if I have to stop lessons before June, 2018, I will inform Astoria Dance Centre 2 weeks in advance.  I understand that in order to be removed from the autopay system I must fill out a withdrawal form and submit it to the school 2 weeks in advance

I also agree to 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 ____________________________________ Date ________________
Signature of Parent /Guardian if student is under 21 years of age required.
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