IDC REGISTRATION FORM – IRONWOOD FALL 2012STUDENT INFORMATION STUDENT NAME___________________________________________________ AGE ________________________ DATE OF BIRTH________/________/________ GRADE__________ TODAY’S DATE_______________________ PREVIOUS CLASSES: _____________________________________________________________________________ ANY HEALTH OR PHYSICAL RESTRICTIONS IDC NEEDS TO BE AWARE OF? NO_________ YES_________ IF YES, PLEASE EXPLAIN: ________________________________________________________________________ ________________________________________________________________________________________________ PARENT/GUARDIAN (BILLING) INFORMATION PARENT #1:_____________________________________ PARENT #2:_____________________________________ ADDRESS__________________________________ CITY/STATE/ZIP_____________________________________ PHONE: HOME_____________________________ WORK: NAME/#______________________________________ E-MAIL______________________________________________________ CELL _____________________________ IN CASE OF EMERGENCY, PLEASE CONTACT: _____________________________________________________ PHONE NO. ( ) ______________________________ OR ( ) ______________________________________ DESIRED CLASSES 1. CLASS NAME_____________________________________DAY_____________________TIME_______________ 2. CLASS NAME_____________________________________DAY_____________________TIME_______________ 3. CLASS NAME_____________________________________DAY_____________________TIME_______________ NEW STUDENT NO______ YES______ ($10.00 New Student registration fee) ANNUAL RATE ________________SEMESTER RATE _________________ MONTHLY RATE _______________ AMOUNT DUE____________________ CASH_____________ CHECK #_____________ I (we) have read and understand the IDC 2009/2010 Dance Season program information and studio policies. I understand that participation in this dance program is voluntary and strenuous, and verify that I and/or my child/children are physically fit to participate. I waive and release Ironwood Dance Company Inc., Margaret Grachek, Instructors, their heirs and their assigns from any and all rights and claims for injuries suffered or medical expenses which may occur as a result in the participation in this dance season. Parent/Guardian Signature_____________________________________________ Date ______________ Photography Release I hereby grant absolute right and permission to the Ironwood Dance Company Inc. to use photographic portraits of my child/children for illustration, promotion or advertising purposes. I have read and agree to the above statement. ______Yes _____No Make checks payable to: Ironwood Dance Company Inc. All questions regarding tuition and registration should be directed to and registration forms sent to: Ironwood Dance
Company Inc. Phone (906)932-1661 Cell (906)364-3221or e-mail: margaret@ironwooddance.com |
