REGISTRATION FORM/AUTOMATIC PAYMENT CONSENT FORM

2011-2012 Tuition

Dance

1 – 30 Minute Class Per Week                        Monthly Tuition $47

1 – 45 Minute Class Per Week                        Monthly Tuition $47

1 – 60 Minute Class Per Week                        Monthly Tuition $52

1 – 30 Minute Pointe Class Per Week           Monthly Tuition $25

Unlimited Classes                                            Monthly Tuition $230
  * Unlimited rate is per student, not per family. To be eligible for unlimited, the student must be registered for six or more classes.

10% Multiple dance class discount for students taking more than one class, or more than one student per family

(10% off each class)

Registration Fee - $12 Per Student, $24 Per Family- 2 or more children (Non-refundable)

Registration Fee and June 2012’s Tuition is due at time of Registration and are                                NON-REFUNDABLE.

Tuition is due by the first of the month. If not received by the 7^th there will be a $10 late fee.

Any checks that are returned will be assessed a $15 fee.

5% discount on tuition if paying for the entire season in full.

Student’s Last Name: _______________________________
 Student’s First Name(s):_______________________________

__M __ F Student Birth-date: _________________________ 
Parent’s Name:____________________________________

Phone #: _________________________________ 
Work/Emergency Phone #: ____________________________________

Address: ____________________________________________________________________________________________

E-mail (Required):_____________________________________________________

Where you heard about us: 
__ Referral________________________________ 
__Other_____________________________________________________

Date Registered:____________________________ 
Date Starting Lessons: ____________________________

Class Day(s) Times(s) ______________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________

Medical Conditions: __�No __Yes______________________________________________________________________________

Method of Automatic Payment

__Checking Account – attach voided check here

Card Holder’s Name ______________________________________________________________________________________

Billing Address __________________________________________________________________________________________

__ Visa __Master Card #____________________________________________________________________________________

Expiration Date_________________________________ 

I hereby authorize 5-6-7-8 Dance to charge my account the amount of

$__________________ on the first day of each month starting _____________________ and ending __________________.

Please INITIAL

_____   I will give the school office one month’s WRITTEN notice from the first of the month to discontinue these charges. 

_____   I understand that the tuition is based on four classes per month and I am responsible for payment of this tuition (by the first of the month) regardless of any absences.

_____   In the event that student drops, June’s tuition in Non-refundable/transferrable. 

____________________________________________________

Signature

OFFICE USE:

MONTHLY DANCE FEE ______________________

Reg Fee

First Month’s Fee: ______________________ Ongoing Monthly Fee: _____________________

Only regular occurring monthly fees may be paid by auto-debit or credit card. Incidental fees such as recital t-shirt and tights must be paid at the time of ordering.