Student's Last Name: First Name(s):
M F Student Birth date: Age:
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
Date Registered: Date Starting Lessons:
Yes. If yes please describe:
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.