ASTORIA DANCE CENTRE

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

Print and mail this form with your registration fee. 
Music 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:

Music Lesson:
Music Lesson:
Instructor Name:
Instructor Name:
Instrument:
Instrument:

Medical Conditions: No Yes

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I understand that if I have to stop lessons I must give two (2) weeks notice in writing. The withdrawal must be done in person, in writing, with a desk staff member (not a teacher). Once the drop form is filled out, your scheduled Auto Pay is stopped immediately.  Auto Pay schedules are not suspended until written notice is submitted.

I understand that the $40.00 registration fee is non-refundable and that there are no credits or refunds on music lesson fees.

I understand that the make up lesson policy is only if the student is sick and that make ups are limited to 2 times per year.

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.

By signing below I agree to follow all of the above conditions and those included in the music guideline handout.

Signature ____________________________________ Date ___________________

Signature of Parent /Guardian if student is under 21 years of age required.
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