2623 151st Place NE

Redmond, WA 98052

Studio: 425-867-2300

Fax: 425-861-6745

Email:

Web: www.premieredancecenter.com

2009-2010 Pre-Registration Form

Please Circle One

New Student Returning Student

Student
Last name First Name / Birth date
Address
Street Address / City / State / Zip Code
Contact
Email Address / Home Phone / Cell Phone / Work Phone
Mother or Guardian / Names of family members enrolled
Last name First Name
Father or Guardian
Last name First Name
Does student have any life threatening Medical Conditions? Yes____No____Please describe______
Please tell us how you found Premiere Dance Center Circle One Please
Internet ● Microsoft Prime Card ● Kids Directory ● Parent Map ● School Packet (which school) ● Premiere Birthday Party ● Friend’Name_ ●

THE HOLD HARMLESS & FINANCIAL AGREEMENT:

The undersigned member and their parent(s)/guardian(s) indemnifies and holds harmless Premiere Dance Center and its agents and officers, staff from any liability whatsoever for any damages or injuries and from any and all claims and demands including attorney fees, arising out of the parties participation in dance classes, private lessons, rehearsals and/or performances provided by or participated in, through The Premiere Dance Center. We suggest you consult your physician prior to participation.

In addition (CIRCLE ONE PLEASE I do or I do not) give permission for Premiere Dance Center Staff to authorize Emergency Medical Treatment for the above named student in the event that they find necessary.

I hereby assume all Financial Responsibility for the above student enrolled at Premiere Dance Center. I further understand I will be charged for all classes until I have notified PDC in writing of my child’s withdraw from classes. In event it becomes necessary to refer this account for collection, you (as the parent/guardian) will be liable for all collection fees, including attorney fees, interest, etc.

RETURNED CHECKS FEE: There will be $25.00 NSF fee collected for all NSF checks

NO REFUNDS:Missed classes must be made up withinsession of missed class. NO CASH REFUNDS are given. NO TUITION IS TRANSFERABLE..

I HAVE READ AND UNDERSTAND THE ABOVE POLICIES

X X

Signature (of parent if under 18) Date

Day / Time / Class / Instructor / Hours
to
to
to
to
Start Date / Yrs of Dance / Discount Type / Hours Registered Per Week
Payment Form / Automatic Payment Authorization or
Credit Card Phone Order Authorization / Tuition w/ discount (if applicable)
Adult Punch Card / $100.00
Credit / Signature on File / End of Year Recital Costume Fee / $65.00
Cash / Master Card or Visa # / / Registration Fee / $25.00
Check # /

CC Expiration Date

/ V-Code: / Discount
By: /

Microsoft Prime Card #

/ MSPC Exp Date: / Total

TRIAL CLASS DATE______