STEPPIN'OUT DANCE ACADEMY
52 Church Street, Kingston, NH
603-642-7711 

Click here to edit subtitle


STEPPIN’OUT 2018-2019 FALL REGISTRATION FORM


Parent 1 First Name:__________________________ Last Name:_________________________________


Phone 1:____________________________________ Phone 2:___________________________________


Parent 2 First Name:__________________________ Last Name:_________________________________


Mailing Address:________________________________________________________________________________


Email Address:_______________________________________________________________(for studio newsletters)


Student #1 First Name:________________________ Last Name:_________________________________


Birthdate: __________________________________ Age:_______________________________________


Student #2 First Name:________________________ Last Name:_________________________________


Birthdate: __________________________________ Age:_______________________________________


(ADDITIONAL STUDENTS PLEASE USE BACK OF REGISTRATION FORM)


PLEASE LIST CLASS/CLASSES STUDENT/STUDENTS WILL TAKE


Student # Class Name Day & Time Instructor


_____________________________________________________________________________________________


_____________________________________________________________________________________________


_____________________________________________________________________________________________


_____________________________________________________________________________________________


_____________________________________________________________________________________________


Medical Conditions or Allergies:____________________________________________________________________


Registration Fee Enclosed:$_______________ September Tuition Enclosed:$_____________


I am responsible for fees for all services rendered. I have read and understand the tuition policy for dance and aerial classes. I agree to allow Steppin’Out Dance Academy, Corp. to automatically charge my credit card for any balances or fees that are past due on my acct.

I understand that I will receive a $10 charge if my card on file is declined a second time. In consideration of the benefits derived from Steppin’Out Dance Academy, Corp., I (we) do hereby agree to hold harmless the Steppin’Out Dance Academy, Corp., it’s agents or employees for any and all claims of personal injuries to myself, my (our) son(s)/daugther(s)while participating in said dance, aerial, fitness, or other activities on the premises.

I understand that photos and videos may be taken throughout the year, and these images may be published or used for advertisement or promotional purposed by Steppin’Out Dance Academy, Corp, and it’s agents. I relinquish my right to protest any such use, or receive compensation of any type.


CREDIT CARD TO KEEP ON FILE:_______________________________________ EXP. DATE:____

(required)

*I elect to have my monthly tuition fees automatically charged to the card on file: Yes:___ No:____


Parent or Legal Guardian Signature:_________________________________________ Date:__________


Please Print Name:_____________________________________________________________________________