Patsy’s Dance Studio

2020 – 2021 Registration Form

Registration fee is $20 per Family

Students of dance

Name _____________________________ Age______Birth date __________________

Name _____________________________ Age______Birth date __________________

Name _____________________________ Age______Birth date __________________

Day/class time preferred for each student:




Parent’s name & address: _____________________________________________________________________________

Contact cell No. ___________________________________________________________

Emergency Contact Name & telephone No. _____________________________________________________________________________

PHOTOGRAPHIC RELEASE: I give permission for photos of my child to be taken during dance classes.
Photos will be used on social media and for advertisements. ____yes ____no


/__/  I will pay monthly payments and I understand that monthly payments are due on the first class of the each month and no later than the 15th of the month to avoid a $10 late fee per month until paid in full. Classes can also be paid bi-yearly with a 5% discount or yearly with a 10% discount if paid for the year.

/__/  I will pay the costume deposit of $100 (2 costumes) or $150 (3 or more costumes) by November 1, 2020.  Balance will be due by February 1, 2021.

RELEASE OF LIABILITY:  I, the undersigned, recognizing that classes involving physical activity may result in personal injury, do release Patsy’s Dance Studio & her staff from ALL liability. In the case of emergency, if I or my emergency contact cannot be reached, I authorize Patsy or her staff to secure medical assistance. I have taken the necessary steps in obtaining accidental, health, or hospitalization insurance that would cover any sustained injury.

--Parents are responsible for the safe & timely drop-off & pick up of all dancers at the back door. No parents or siblings are to be in the dance studio during class time.

--Put dancers name on ALL shoes & articles of clothing please.

Signed by (Parent or legal guardian or adult student)
For office use only
Monthly fee(s) $____________, $____________, $____________ TOTAL $____________

Paid registration fee $20 per family YES _____   NO _____

Paid bi-yearly $________    Paid yearly $________
Amount paid $ ________ Check #_________ Cash___Credit Card____PayPal_____