~ Registration Form ~

Student Last Name:

Student First Name:

Street Address:

Mailing Address:

City:

State & Zip Code:

Birthdate:

School & Grade:

Parent Name:

Email Address(es):

Work/Home Phone:

Cel Phone:

Parent Name:

Email Address(es):

Work/Home Phone:

Cel Phone:

Emergency Name:

Emergency Phone:

Previous Dance Experience:

Class Schedule
Supplies

Class 1:

Item                 Size       Color     Quantity    Cost     Recv'd

Class 2:

Leotard

Class 3:

Tights

Class 4:

Ballet Slippers

Class 5:

Tap Shoes

 

Jazz Shoes

 

Misc Items

 

 

Total Tuition Cost: $

Total Supplies Cost: $

NOTES:

Payment Information

Tuition Total:               $

Receipt #:                             Check #:

Supplies Total:            $

Amount Paid:  $

Registration Fee:        $     5.00

Balance Due:  $

Miscellaneous Total:  $

Account Notes:

CBJ 5% Tax:                $

 

Total Amount Due:     $

 

I have read the School Policy and understand the tuition, attendance, refund, and dress code policies.  I will be responsible for financial payments of all costs incurred.  I give my permission to Janice D. Holst to use photos of the person registered on this form in any promotional effort.  I understand that photos for this purpose may be taken at any Janice D. Holst activity.  I also understand that videotaping of classes, rehearsals and performances is strictly PROHIBITED under any circumstances by myself, other family members and/or friends. Thank You J

Signature of Parent/Guardian:_____________________________________  Date: __________________
PLEASE COMPLETE THE LIABILITY WAIVER ON THE BACK OF THIS FORM→→→→→→→→→→→

586-1462 Tel / 723-1462 Cel / 586-2682 Fax / Holst@gci.net


Jance D. Holst School of Dance

Site created & maintained by
Annie's Dragon Lair
Juneau, Alaska