1. 2012/13 Registration Form Dancer’s Name________________________________ Age______Birthdate_________________ Parent/Guardian_________________________________________________________________ Mailing Address ______________________________________Zipcode_____________________ Home#___________Work#__________Cell#___________Email___________________________ List Class(es) to be taken: Class________________________ Day ___________________ Time______________ Class________________________ Day _______________________ Time______________ Class________________________ Day ___________________ Time______________ Class________________________ Day _______________________ Time______________ PAYMENT OPTIONS: *Paid in full, 2% discount if received on or before registration $_____________ No REFUNDS for tuition paid in full. *I agree to make 9 payments of $__________. Monthly Tuition of $____________ is due no later than the first dance class your child has following the 1st of each month. The 2 nd tuition payment due in September during the FIRST WEEK of classes. The 7 remaining payments are due no later than the first dance class your child has following the 1st of each month beginning in October...NO MAY PAYMENT.) I understand that a $15 late fee will be added to my account if payment is not made. I agree to have my child at all scheduled rehearsals for our end of the season shows. I understand that if my child misses either show without an approved reason, they will not be able to participate in the following year’s dance curriculum. I understand that all tuition/fees must be paid in full by March 30, 2013 in order for my child to perform in our shows. I am aware that all forms of dance and the acrobatic exercises associated with it, place unusual stresses on the body and carry with them the risk of physical injury. I assume this risk and agree that Gotta DANCE! School of Performing Arts, Inc., its staff, and the facilities of this dance school shall not be liable in any way for injuries sustained during attendance of the programs or any of its functions. If I do not wish to have my child’s picture printed in the newspaper or any other publication, I will put this in writing and submit to the Owner. Total Amount necessary to reserve class space: $20 Registration Fee per student ______ *Families pay ONE Registration Fee. $_________ 1st Tuition Payment --OR-- $__________ Tuition Paid in Full $_________ Total Amount Paid: Registration Fee and 1 st Tuition Payment Check#________ V/MC_____________________________________ Exp Date_____________ $15 Late Fee will be applied each month a payment is delinquent to all accounts. $25 charge assessed to any returned checks. Parent/Guardian Signature_______________________________ Date_____________ Register in person - Or - Mail form and payment to: Tara R. Peyton-Burgess, Owner, Artistic Director, 6317 Courthouse Road, Prince George, VA 23875 You can mail in your registration form and payment prior to our registration dates to reserve your child’s spot in a class. Students will be placed in classes on a first come first serve basis. Classes do fill and close so don’t delay registering.