Dance Grosse Ile ____       Dance Brownstown____

Dance Trenton  ____    Dance Gibraltar____

*Mark the program that applies to you*

Registration Form 2011-2012

 (Please Print)

Child’s Name: _____________________________          Class Type            Day         Time                 

Address_________________________________          Course #1 ___________________________                         

City/State/Zip __________________                                  Course #2 ___________________________                                        

Phone # _______________________                                 Course #3 ___________________________                                       

                                                                                                                                                                                                                                                                           Course #4 ___________________________                                             

Birthday: __________________                Male_____ Female _____Age _____Grade _____                                        

Office Use Only

Date Paid: _________

Cash _______ Check ________ Cr. Card _______________

Receipt # _____________                 

Course Fee _________________

Email: ____________________________  

Sept. _________

Oct. _________

Nov. ________

Dec. _________

Jan. __________

Feb. __________

Mar. __________

Apr. __________        

May__________

June __________

Waiver for Participation

In consideration of your acceptance of my child’s registration in this program, I do hereby, for myself, my child, my heirs, and personal representatives, waive release and forever discharge any and all rights and claims, for damages which I, or my child may have or which hereafter accrue to me or my child against all municipalities, school districts, and properties through which the program will be held on and its or their respective officers, instructors, administrators, successors, and/or assigns for any and all damages which may be sustained or suffered by me or my child in connection with said association with this program and my or my child’s participation therein.  I further represent that I and my child are in good physical condition and have no disability or ailment that will prevent me or my child from engaging in the activity for which I or my child is registered.

Signature: ____________________________            Date: ____________________

In case of emergency call: _______________________          Phone: ________________

You are pre-registered for these classes.  You must register by your program’s registration date (see below) to keep your place in class.  Payment is due for the first semester at this time.  If you need an alternate payment method, please see Ms. Gina.  Remember: During registration, shoe fitting and dance apparel will be available. Classes resume the week of September 12^th, 2011.

Trenton: Monday, August 23^rd   (5 p.m.-9 p.m.)      

Gibraltar: Wednesday, August 25^th (5 p.m.-9 p.m.)

Brownstown: Friday, Aug. 27^th (5 p.m.-9 p.m.) Saturday, Aug. 28^th (11a.m.-3p.m.)

Grosse Ile: Tuesday, August 24^th and Thursday, August 26^th  (5 p.m.-9 p.m.)