MEDWAY DANCE AUTHORITY 2009 - 2010 REGISTRATION FORM (one form per student please)
STUDENT’S NAME __________________________ PARENT’S NAMES ___________________________
STUDENT’S BIRTHDATE ________________ EMAIL___________________________________________
STUDENT’S ADDRESS ____________________________________________________________________
TOWN ____________________________________ ZIP CODE_____________________________________
PHONE NUMBER ______________________ CELL PHONE______________________________________
EMERGENCY CONTACT (OTHER THAN PARENT) ___________________________________________
EMERGENCY CONTACT PHONE NUMBER __________________________________________________
RELATIONSHIP TO STUDENT _____________________________________________________________
ALLERGIES/PHYSICAL LIMITATIONS ______________________________________________________
_________________________________________________________________________________________
PHYSICIAN’S NAME_______________________________ PHONE________________________________
PHYSICIAN’S ADDRESS___________________________________________________________________
INSURANCE______________________________ POLICY NUMBER_______________________________
PREVIOUS DANCE EXPERIENCE:
DANCE SCHOOL _________________________________________________________ YEARS
_____________________________
TYPE OF
DANCE____________________________________________________________________________________________
__
PHOTO RELEASE I, ___________________________________, give the Medway Dance Authority permission to use my
child’s photos from studio events for use on The Medway Dance Authority Website, Advertisements & Studio Brochures.
How did you hear about the The Medway Dance Authority (Please circle):
Website Newspaper Business Card Display Referred By: ___________________________
REGISTRATION FEES
$25.00 Single Student Registration Fee is Due
or
$40.00 Family Registration Fee Is Due
All currently enrolled students may register as of April 1st – NO SOONER!!! Forms turned in early will be returned.
Siblings, except age 3, must wait until April 15th to enroll.
Siblings forms should be turned in before April 15th for preferred placement over new students from outside the school.
Registration forms may be mailed to: The Medway Dance Authority P.O. Box 150 Medway, MA 02053
Priority enrollment for current students will be April 1st – April 14th. Registration will be first come, first serve during this time
for current students. If you need a particular day and time you should try to register early. You may enroll by filling out this
registration form and enclosing it in an envelope with your registration fee (see fees above). Please make sure you fill in the
correct day, time, and cost of classes. Please see me first if your child wishes to try a new style of dance. His/ Her class may
not be the level indicated above and he/she may need to wait for a slot to open. If you do not hear from us your child will
automatically be enrolled in the programs you have requested on the back of this form. If a class is full we will contact you
immediately! Please call 533-9171 with any questions you may have!
REGISTRATION FORM & CONTRACT
Please register my child, _________________________________ for the 2009 - 2010 dance season. I have enclosed my
non-refundable registration fee of $25.00 for a single student or $40.00 for a family registration to register for the classes
below. I will contact The Medway Dance Authority by September 1, 2009 if we will not be able to attend the 2009/2010
season. I understand that tuition if not paid in full by September 1, 2009 will always due by the 1st day of each month
(September 1st – May 1st ) and that I will be charged a $10.00 late fee after the 1st day of the month. I understand that I will
NOT receive the 10% multi-class discount if my payment is late and will also be required to pay the $10.00 late fee. I also
agree to pay a $20.00 penalty for any returned checks.
I understand that the costume payment of $60.00 per class is due by October 15, 2009. This payment must be made
separate from tuition and is non-refundable. However, if the costume payment has been made, but the child is unable to
continue in the dance program, he/she will still receive his/her costume.
I understand my payment options. I understand that payment may be made in full for the year by September 1st or I may
choose to make 9 equal payments September 1st – May 1st. I understand that tuition is based on the dance season, not
based on how many classes per month.
I understand that my child must follow all studio rules and safety regulations. My child will also be at class on time so that
he/she will not miss critical warm up exercises. I understand and my child understands that by missing class time and by not
following rules, he/she runs the risk of injuring himself/herself. I also understand that with any physical activity, including
dance, there is always a risk of injury and I will not hold The Medway Dance Authority and it’s representatives responsible for
any injuries.
I, ____________________________________________________ and my child_________________________________
will follow all of the rules & regulations of The Medway Dance Authority as outlined in the handbook. 2009/2010
handbooks must be signed out by a parent or guardian at the first dance class.
Please register ___________________________________________ for the following classes.
CLASS DAY TIME COST
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
YEARLY TUITION TOTAL MONTHLY INSTALLMENT (If you choose Option C)
____________________ _______________________
Families enrolled for more than 1 class may take a 10% discount monthly if payments are made by the 1st day of
each month!!!
1ST payment of Option 3 monthly installment payment plan due by September 1, 2009
Receive a 5% discount if full year is paid by June 15, 2009
(May be combined with 10% multi –class discount if you are eligible)
REGISTRATION FEE DUE NOW!!!
$25.00 single student/$40.00 Family
_____OPTION A I choose to Pre-pay the 2009/2010 Season in full by June 15, 2009 to receive the extra 5%
Discount (10% Multi-class discount may also be added if applicable for a savings of 15%) Payment may be
dropped off at the dance studio or mailed to: The Medway Dance Authority P.O. Box 150 Medway, Ma. 02053
______OPTION B I choose to pay for the 2009/2010 season in full by September 1, 2009 (10% Multi-class discount
may be taken if applicable )
______ OPTION C I choose to break my 2009/2010 payment into 9 payments, due September 1, 2009 through
May 1, 2010 (10% Multi-class discount may be taken if payments are made on-time (by the 1st DAY of each month,
not the 1st class) The multi-class discount may not be taken if payment arrives after the 1st day of the month. A
$10.00 late fee will also be due if payments are late.) * Note that we are going back to a 9 payment schedule
rather than 10 payments for 2009/2010
OFFICE USE ONLY
REGISTRATION FEE PAID BY: CASH OR CHECK #__________ ON / /
If paying in full, please indicate amount and date paid: $______________ on / /
