Registration Form

Student's name: ________________________

Age: _____

Guardian's name: _______________________

Relationship: __________________

Address: __________________________

City/state: ____________________

Zip: _________

Home Phone #: ___/___________

Alternate #:____/___________

Emergency Contact Name/Number: _______________________

How did you hear about us? __________________________

Payment Information

Class(es): _____________________________________________

Session Fee: $__________

Pro-rate Fee: $ __________

Payment Received (Date): __________________

Cash

Check (Make payable to City Dance Studio) CHK# __________

Credit Card (please circle):   MasterCard    VISA     DISCOVER    AMEX

Credit Card Number: _______________________

Exp. Date: ___________

Name of Card Holder: ______________________________________

Signature: _______________________________________

For Office Use Only

Processor: ___________________________________

Date: _________________

Comments: __________________________________