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:
Medical Conditions: No Yes
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.