Registration Form
2011-2012
Please return this form with a $25 registration fee and mail to:
Meriden Dance Center
626-632 E. Main Street, Unit #9
Meriden, CT 06450
Student's Name:____________________________________________________________
Date of Birth: _______________________________________________________________
Address:___________________________________________________Apt. # ___________
City:___________________________________State:_______________Zip:_____________
Home #:__________________Cell #:__________________Work #:____________________
Email Address:______________________________________________________________
Previous Experience:_________________________________________________________
This is my child's _________ year at this studio.
Classes Desired (include day and time):__________________________________________
___________________________________________________________________________
___________________________________________________________________________
Medical Conditions:__________________________________________________________
___________________________________________________________________________
Parent's Name(s):____________________________________________________________
Referred by:_________________________________________________________________
Signature:__________________________________________________________________
The over signed for self and/or minore child agrees to hold harmless Meriden Dance Center, its instrutors and support staff, for any injuries or illness that may result from said participation or transportation associated herewith. The over signed further authorizes a representative from this school to obtain any medical treatment they deem necessary for self and/or minor child. Photod and video may be used to promote school. please advise us if this is not all right with you.
Please choose one of the following convenient payment options:
(costume fees will be included in the 1st 3 installments)
1. Payment in full due August 25th by cash, check, or credit card.
2. Payment in 2 installments due August 25th and December 15th by cash, check, or credit card.
3. Payment in 10 installments due the 25th of the month prior by:
a. auto debit from checking account (vioded check needed)
b. debit from credit account (fill out information below)
Auto debit from credit account, please choose one:
Visa Master Card Discover
Card #:_____________________________________________________________________
Exp. Date:__________________________________________________________________
3-Digit Auth. from back of card:_________________________________________________
Card Holder's Name:_________________________________________________________
Card Holder's Signature:_______________________________________________________
I hereby authorize Meriden Dance Center to charge my account in the amount of:___________on Aug 25, Sept 25, & Oct 25th 9tuition plus costume installments) and____________________ on Nov 25th, Dec 25, Jan 25th, Feb 25th, Mar 25th, Apr 25th, May 25th.
All charges will appear as Meriden Dance Center. I will give the school one month's written notice from the first month to discontinue these charges. I hereby authorize the school to debit my account from any NSF from checking transactions plus a $20 NSF fee.