Registration Form

Encore Dance Registration Form:

*For a printable version of this form, CLICK HERE

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Student’s Last Name First Name Boy or Girl   Age    Date of Birth

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Parent’s Last Name First Name Parent’s E-mail Address

_____________________________________ __________________________ ___________
Address City Zip

(___)__________________________ (___)___________________ (___)___________________
Home Phone   Cell Phone Work Phone

Emergency Contact :

Classes Signing up for:

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Please tell us anything else you’d like us to know about your child, including health issues or allergies, favorite things etc.  Anything to help us get to know your child!

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Credit Card:  Visa  Mastercard Disc  CC#__________________________Exp. Date:_______
(Credit Card information may be called in if you are more comfortable) 

I have read and agree to abide by the policies of Encore Dance.  I further agree to release all claims, liens and liabilities towards Encore Dance, its employees and agents acting on its behalf.

__________________________________________ __________________________________
Parent/Guardian Signature Date