Midwest Dance Center

Registration Sheet

Last Name: _________________________________________Parents Name: _________________________________________________

Parent Information

Address:__________________________________________________________________________

City: _________________________State:_________________________ Zip:__________________

Home Phone:__________________ Mom's Wk:_________________ Dad's Wk:________________

Mom's Cell:__________________ Dad's Cell:__________________ Student's Cell: _____________

Emergency Contact Name: _______________Home Phone:______________ Cell Phone:_____________

Home Email:_______________________ Student's Email: _________________________________

Mom's Wk Email: ___________________________Dad's Wk Email:_________________________

Family Discounts: 2 or more students 5%. Exceptions: The discount does not apply if the student is on a competitive dance or cheer team, only the additional student(s) not on a competitive team will receive the discount.

I understand that the tuition is due the 1st class of the month and after the 15th of the month there will be a $5 late fee assessed. There is a $30 Return Check fee. Classes missed for personal reasons and weather may be made up by attending an additional class. See your instructor for times. All tuition, registration, recital fees, competition fees, and costume fees are non-refundable.

Signature: ___________________________________________________________________________