CELEBRATING 40 YEARS IN BELLEVUE!
Open the door to the wonderful world of
DANCE - DO IT TODAY!
 REGISTRATION INFORMATION
Register in person, by mail, fax, or e-mail. Please call: (425) 454-6008
FAX - 425-454-4960 or e-mail: danceacademyofbellevue@msn.com
When emailing please include your daytime phone.

----REGISTRATION FORM FOR CLASSES-----
Session: (please circle) .......Fall........... Spring........ Summer......... Summer Camp

Class Title:________________ Time/Day:__________________Instructor: __________________

Class Title:________________ Time/Day:__________________Instructor: __________________

Student's Name: _____________________ Age:_________ Birth Date:_________

Address:_________________________ City:_________________ State:_________ Zip:_________

Phone:______________ Emergency Cell Phone:______________ EMail:________________________

Emergency Contact:______________________

Preference for contacting you? Postal Mail Home Phone Cell Phone E-Mail
May we share your Phone/e-mail with other dance
academy parents for our phone tree?... Yes.... No
The person usually taking me to dance class will be:
Parent: ______ Grandparent: ______ Nanny:______ Friend:______ My Self: _______

PAYMENT INFORMATION: TO BE PAID BY: _______________________________

Method of Payment: (Please circle) ...Visa..... AMX Disc. ....MasterCard......Cash .....Check

Card # : ______________________________Exp. Date: _________

I would like to make a payment for: Yearly Tuition (Pd by Sept. 10th ) Quarterly Tuition: 8 weeks Auto-Payment plan? Yes No Payment Amt: $ ______ (Taken out every 8 weeks, btw. 1st-5th )
Same Card? Yes No, New Card # ____________________________ Exp. Date: __________
Registration Fee: $25 Plus (+) Dance Class Tuition Fee: $________ Total = $______________
There are no refunds, credits, extensions or transfers of any tuition.

Hold Harmless Agreement
The undersigned Parent/Student indemnifies and holds Harmless the Dance Academy of Bellevue and its agents, from all 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 lessons and and performances Provided by the Dance Academy of Bellevue. I have read the above and understand the terms and conditions of this registration form.

Parent's signature if Student is under 18: _________________DATE: ________

Grandparent/Nanny (if Necessary): ______________________DATE:________