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MS. KAREN'S DANCE STUDIO
ENROLLMENT FORM
-Please Print-

 

Name (1) ______________________________________________ Age __________ Birthdate ___/___/___

          (2) ______________________________________________ Age __________ Birthdate ___/___/___

          (3) ______________________________________________ Age __________ Birthdate ___/___/___

Parents Name ___________________________________________________________________________

Address _____________________________________________________________ Zip _______________

 

Telephone -

Home

  ________________________________________________________
  Mother's Work  ________________________________________________________
  Father's Work  ________________________________________________________
  Mother's Cell  ________________________________________________________
  Father's Cell  ________________________________________________________

Emergency Call (Name) ______________________________________________________________

                        (Phone) ______________________________________________________________

    Day Time Class
Class Preference 1)  _____________________________________________________________________
  2)  _____________________________________________________________________
  3)  _____________________________________________________________________
  4)  _____________________________________________________________________
  5)  _____________________________________________________________________
  6)  _____________________________________________________________________

First Month Tuition Due Upon Registration

I will not hold Ms. Karen's Dance Studio responsible for any injury sustained by myself or my child anywhere on or outside the premises.

Signature  _________________________________________________________
Date  _________________________________________________________
1st Month's Payment  _________________________________________________________
Registration Fee ($30 / $50) Family  _________________________________________________________
Total Enclosed  _________________________________________________________

 

Return to: Ms. Karen's Dance Studio
  PO Box 94194  #6 Parkstone Circle
  North Little Rock, AR 72190