IDC CLASS REGISTRATION - 2013/2014 SEASON

STUDENT INFORMAITON

STUDENT NAME________________________________________________________________ AGE _______________________

DATE OF BIRTH_________/_________/_________ GRADE____________ TODAY’S DATE______________________________

PREVIOUS CLASSES: ________________________________________________________________________________________

PARENT/GUARDIAN (BILLING) INFORMATION

PARENT #1: _______________________________________ PARENT #2 ______________________________________________

ADDRESS_______________________________________   CITY/STATE/ZIP___________________________________________

PHONE: HOME_________________________________________   CELL #_____________________________________________ 

E-MAIL ____________________________________________________________________________________________________
                                          (Required to receive your studio newsletter and ALL IMPORTANT CLASS UPDATES)

PLACE OF EMPLOYMENT: ______________________________________________WORK # _____________________________

IN CASE OF EMERGENCY, PLEASE CONTACT:  ________________________________________________________________

                                PHONE # (          ) ___________________________________ CELL # (          ) ___________________________________________

DESIRED CLASSES

1. CLASS NAME_______________________________________DAY_________________________TIME____________________
 

2. CLASS NAME_______________________________________DAY_________________________TIME____________________
 

3. CLASS NAME_______________________________________DAY_________________________TIME____________________
 

4. CLASS NAME_______________________________________DAY_________________________TIME____________________

Student Registration Fee – All Students $10.00

ANNUAL RATE ____________ SEMESTER RATE _____________ MONTHLY RATE _____________ AMOUNT DUE $_________________
 

METHOD OF PAYMENT MONTHLY:  CASH_______ CHECK #_______ AUTO-DEBIT _______ OTHER______________


CREDIT CARD – Fill out below

Credit Card # _____________________________________________ Exp. Date: ______________________ S.Code # __________

I hereby authorize Ironwood Dance Company Inc. to charge my account the tuition amount of $____________________ on the first day of each month beginning ___________________________ and ending ___________________________________. 
All charges will appear as IDC.  I will give the studio office one month’s written notice from the 1^st of the month to discontinue these charges.

_____________________________________________________________________     ___________________________________
Signature                                                                                                 Date

There will be a 3.5% fee credit & debit card payments to cover the fees charged by those companies.

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.  E5053 Slade Rd.  Ironwood, MI  49938

Phone (906)932-1661 or e-mail: margaret@ironwooddance.com