Extreme Dance Studio

Dancer's Last Name

Dancer's First Name

Address

City/State/Zip

Phone

Age

Date of Birth

Billing Email Address

Studio Information Email Address

Mother/Legal Guardian Last Name

Mother/Legal Guardian First Name

Address

City/State/Zip

Cell Phone

Phone

Father/Legal Guardian Last Name

Father/Legal Guardian First Name:

Address:

City/State/Zip

Cell Phone

Phone

Emergency Contact Other Than Mother or Father

Name

Relationship to Dancer

Phone

Please list all known allergies or health conditions:

Dance Class, Day & Time:

Total Amount Due Each Month:

*There will be no makeup classes or refunds for canceled classes due to inclement weather or holidays.

**All other Summer Class payments are due June 5th, 2024 and the $20.00 registration fee or at the time of registration if after this date. All payments are 7 week prices. We offer a pay in full or a 4 week and 3 week payment plan for our 7 week Summer Classes. A late fee of $10.00 per class per week will apply if paid after the due date. All cards on file will be charged a $25.00 reprocessing fee if declined or come back as do not honor. Please make us aware 10 days prior to the payment coming out if you need to change your card on file, otherwise you may be charged a late fee as well as a reprocessing fee.

Please check one of the following:

I give permission for my dancer's picture to be taken/used for social media purposes/advertising

I do not want my dancer's pictures taken or used for social media purposes/advertising.

Signature:

Date:

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