Division: (For Office Use Only)

REGISTRATION FORM

In order for your child to receive priority status in class placement, we encourage you to register early. The registration fee is $35, for all new students, not to exceed $50 per family. For all students currently enrolled, the registration fee is $25 per student, not to exceed $50 per family. Please be sure to include all necessary information on the enclosed form so that we may place your child in the appropriate class.

DIVISION: (FOR OFFICE USE ONLY)

___ Preschool ___ Primary I ___Primary II ___Beg/Elem ___Int/Elem ___Beg/Sec ___Int/Sec

2 ½ -3 4-5 6-7 8-10 8-10 11-13 11-13

___ Teen ___Specialty ___Adult ___Jr. Company ___Teen Company ___Sr. Company

14-up (All company classes are by audition only.)

FALL ______SUMMER ______PAYMENTPLAN ____ A ____ B ____ C

STUDENT NAME (LAST) ______(FIRST)______

DATE OF

BIRTH ______AGE ______E-MAIL ______

HOME PHONE ______CELL PHONE ______PAGER ______

FAMILY ADDRESS ______

CITY/STATE ______ZIP CODE ______

BILLING ADDRESS(IF DIFFERENT FROM ABOVE)______

CITY/STATE ______ZIP CODE ______

MEDICAL PROBLEMS:

______

______

EMERGENCY CONTACT: NAME ______

RELATION TO STUDENT ______PHONE ______

MOTHER’S NAME ______WORK PHONE ______

PLACE OF EMPLOYMENT ______

FATHER’S NAME ______WORK PHONE ______

PLACE OF EMPLOYMENT ______

HOW DID YOU HEAR ABOUT JEAN LEIGH? ______

SCHEDULING INFORMATION

STUDENT WILL BE ENROLLING IN THE FOLLOWING CLASSES:

BALLET ____ TAP ____ JAZZ ____ ACROBATS ____ MODERN ____ HIPHOP ____ OTHER ___

PREVIOUS DANCE EXPERIENCE

(Please list the courses taken and the number of years. Also include instructors’ names and the studio.)

______

______

______

SO THAT WE CAN BEST ACCOMMODATE YOUR SCHEDULING NEEDS, PLEASE RATE THE FOLLOWING 1-6, (1-BEING YOUR PREFERRED DAY AND 6-BEING YOUR LEAST PREFERRED.)

MONDAY ___ TUESDAY ___ WEDNESDAY ___ THURSDAY ___ FRIDAY ___ SATURDAY ____

WHAT TIME OF DAY OR EVENING DO YOU PREFER? BEST TIME ______AS EARLY AS ______

NOTE: ALL STUDENTS IN COMBINATION CLASSES ARE REQUIRED TO TAKE BALLET. STUDENTS MUST BE AT LEAST 8 YEARS OLD TO TAKE JAZZ.

LIABILITY DISCLAIMER

JEANLEIGHACADEMY OF DANCE AND THE INSTRUCTORS ARE NOT LIABLE FOR PERSONAL INJURIES OR LOSS OF, OR DAMAGE TO PERSONAL PROPERTY. EACH STUDENT MAY DECLINE TO PARTICIPATE IN ANY ACTIVITY. PLEASE INFORMTHE INSTRUCTOR OF ANY PHYSICAL LIMITATIONS YOU MAY HAVE. IF YOU HAVE ANY DOUBT TO YOUR PHYSICAL ABILITIES, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE PARTICIPATING. JEANLEIGHACADEMY OF DANCE CANNOT DISPENSE ASPIRIN OR ANY OTHER MEDICATIONS.

THANK YOU.

We Reserve the Right to refuse admittance.

PRINT PARENT NAME: ______DATE:______

PARENT SIGNATURE: ______DATE: ______

CHILD NAME : ______

Jean Leigh Academy of Dance exists only because of you. Your comments and suggestions are welcome and vital to our ability to serve your needs.

FOR OFFICE USE ONLY:

DATE ______TOTAL AMOUNT PAID ______CASH ______CHECK # ______

TUITION ______REGISTRATION FEE ______PAYMENT: PLAN A ___ PLAN B ___

FAMILY: YES/NO NAME OF SIBLING/S ______CLASS ______