ASTORIA DANCE CENTRE
September 2012-June 2013
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

Costume Fee(s): ____________________________________________________________________

I understand and agree to pay my tuition installments by AUTOPAY either from my checking account or credit card. I understand that if I have to stop lessons I must give two (2) weeks notice in writing. Once the letter is received I understand that at that time all tuition charges will no longer be charged to my checking account or credit card. If I decide to participate in the year end performances I agree to make my costume payment on or before November 10. I understand that if my costume payment is late that I will pay the $15.00 late fee. I also agree to approve the size of my child’s costume size once they are measured. If you choose not to be in the year end performance please inform us in writing. I agree that if the costume does not fit that I will pay the $15.00 per costume exchange fee. I have also read 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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