| MEDWAY DANCE AUTHORITY REGISTRATION FORM 2022 One form per student please |
STUDENT’S NAME __________________________________________
PARENT’S NAMES __________________________________________
STUDENT’S BIRTHDATE ____________________________________
ENTERING GRADE ________ AS OF SEPTEMBER 1, 2021
EMAIL____________________________________________________
HOME PHONE # ________________________ CELL PHONE # __________________________
STREET ADDRESS _______________________________________________________________
TOWN ______________________________ ZIP CODE______________________
EMERGENCY CONTACT ___________________________________________
EMERGENCY CONTACT PHONE #___________________________________
RELATIONSHIP TO STUDENT
_______________________________________________________________
ALLERGIES/PHYSICAL LIMITATIONS
________________________________________________________________________________________________
IEP OR ANY INFO THAT WILL BE IMPORTANT IN TEACHING YOUR
CHILD________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
PHYSICIAN’S NAME_________________________________ PHONE________________________
PHYSICIAN’S
ADDRESS_____________________________________________________________________________________________________________
INSURANCE COMPANY _______________________________________________
POLICY NUMBER____________________________________________
PREVIOUS DANCE EXPERIENCE:
DANCE SCHOOL ___________________________________________YEARS ____________________
TYPES OF
DANCE_______________________________________________________________________________________
PHOTO RELEASE
I, _________________________________, the parent of ______________________________________
(Please circle one) GIVE / DO NOT GIVE The Medway Dance Authority permission to use my child’s photos
from studio events, recital photos, etc. for use on The Medway Dance Authority Website, Advertisements &
Brochures. Signed________________________________________ Date _______________________
How did you hear about the The Medway Dance Authority (Please circle):
Website Newspaper Business Card Display Referred By: _________________
REGISTRATION FEES
$30.00 Single Student Registration Fee OR $55.00 Family Registration Fee
All currently enrolled students may register now!!!
Registration forms may be mailed to: The Medway Dance Authority P.O. Box 150 Medway, MA 02053
Priority enrollment for current students will be accepted now. 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 call 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 2021 - 2022 dance season. I have
enclosed my non-refundable registration fee of $30.00 for a single student or $55.00 for a family registration
to register for the classes below. I will contact The Medway Dance Authority by September 1, 2021 if we will
not be able to attend the 2021/2022 season. I understand that tuition, if not paid in full by September 1, 2021
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 5% 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 $65.00 per class is due by October 15, 2021. 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, it’s staff and it’s representatives responsible for any injuries or loss of
valuables that may occur during the program.
I, ____________________________________________________ and my
child____________________________________________ will follow all of the rules & regulations of The Medway Dance
Authority as outlined in the 2021/2022 handbook. Handbooks must be picked up by a parent or guardian at the first dance class
in September.
Please register my child, ___________________________________________ for the following classes.
CLASS DAY TIME COST
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
YEARLY TUITION TOTAL MONTHLY INSTALLMENT TOTAL (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, 2021
Receive a 5% discount if full year is paid by June 1, 2021
(May be combined with 5% multi –class discount if you are eligible)
REGISTRATION FEE DUE NOW!!!
$30.00 single student/$55.00 Family
_____OPTION A I choose to Pre-pay the 2021/2022 Season in full by June 1, 2021 to receive the extra 5%
Discount (5% Multi-class discount may also be added if applicable for a savings of 10%) 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 2021/2022 season in full by September 1, 2021 (5% Multi-class
discount may be taken if applicable )
______ OPTION C I choose to break my 2021 - 2022 payment into 9 payments, due September 1, 2021
through May 1, 2022 (5% 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.)
OFFICE USE ONLY
REGISTRATION FEE PAID BY: CASH OR CHECK #__________ ON / /
If paying in full, please indicate amount and date paid: $______________ on / /
PARENT’S NAMES __________________________________________
STUDENT’S BIRTHDATE ____________________________________
ENTERING GRADE ________ AS OF SEPTEMBER 1, 2021
EMAIL____________________________________________________
HOME PHONE # ________________________ CELL PHONE # __________________________
STREET ADDRESS _______________________________________________________________
TOWN ______________________________ ZIP CODE______________________
EMERGENCY CONTACT ___________________________________________
EMERGENCY CONTACT PHONE #___________________________________
RELATIONSHIP TO STUDENT
_______________________________________________________________
ALLERGIES/PHYSICAL LIMITATIONS
________________________________________________________________________________________________
IEP OR ANY INFO THAT WILL BE IMPORTANT IN TEACHING YOUR
CHILD________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
PHYSICIAN’S NAME_________________________________ PHONE________________________
PHYSICIAN’S
ADDRESS_____________________________________________________________________________________________________________
INSURANCE COMPANY _______________________________________________
POLICY NUMBER____________________________________________
PREVIOUS DANCE EXPERIENCE:
DANCE SCHOOL ___________________________________________YEARS ____________________
TYPES OF
DANCE_______________________________________________________________________________________
PHOTO RELEASE
I, _________________________________, the parent of ______________________________________
(Please circle one) GIVE / DO NOT GIVE The Medway Dance Authority permission to use my child’s photos
from studio events, recital photos, etc. for use on The Medway Dance Authority Website, Advertisements &
Brochures. Signed________________________________________ Date _______________________
How did you hear about the The Medway Dance Authority (Please circle):
Website Newspaper Business Card Display Referred By: _________________
REGISTRATION FEES
$30.00 Single Student Registration Fee OR $55.00 Family Registration Fee
All currently enrolled students may register now!!!
Registration forms may be mailed to: The Medway Dance Authority P.O. Box 150 Medway, MA 02053
Priority enrollment for current students will be accepted now. 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 call 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 2021 - 2022 dance season. I have
enclosed my non-refundable registration fee of $30.00 for a single student or $55.00 for a family registration
to register for the classes below. I will contact The Medway Dance Authority by September 1, 2021 if we will
not be able to attend the 2021/2022 season. I understand that tuition, if not paid in full by September 1, 2021
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 5% 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 $65.00 per class is due by October 15, 2021. 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, it’s staff and it’s representatives responsible for any injuries or loss of
valuables that may occur during the program.
I, ____________________________________________________ and my
child____________________________________________ will follow all of the rules & regulations of The Medway Dance
Authority as outlined in the 2021/2022 handbook. Handbooks must be picked up by a parent or guardian at the first dance class
in September.
Please register my child, ___________________________________________ for the following classes.
CLASS DAY TIME COST
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
YEARLY TUITION TOTAL MONTHLY INSTALLMENT TOTAL (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, 2021
Receive a 5% discount if full year is paid by June 1, 2021
(May be combined with 5% multi –class discount if you are eligible)
REGISTRATION FEE DUE NOW!!!
$30.00 single student/$55.00 Family
_____OPTION A I choose to Pre-pay the 2021/2022 Season in full by June 1, 2021 to receive the extra 5%
Discount (5% Multi-class discount may also be added if applicable for a savings of 10%) 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 2021/2022 season in full by September 1, 2021 (5% Multi-class
discount may be taken if applicable )
______ OPTION C I choose to break my 2021 - 2022 payment into 9 payments, due September 1, 2021
through May 1, 2022 (5% 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.)
OFFICE USE ONLY
REGISTRATION FEE PAID BY: CASH OR CHECK #__________ ON / /
If paying in full, please indicate amount and date paid: $______________ on / /