Dance Reflections Registration Form To Register: (1) complete the entire form below, (2) click on the "Print This Form" button at the bottom of the page, and (3) return the completed, form along with a $20.00 check to Dance Reflections. This registration cost is a non-refundable fee. Please make checks payable to Dance Reflections.

Dancer's Name:				Age:
Address:				Home Phone:
City:		Zip:		Birthdate:
Parent or Guardian Name:				Work Phone:
Has student danced previously?: (select one)	Yes No	How Long?:	(select one) - 6 Months 6 Mo's to 1 Yr 1 to 2 Years 2 to 3 Years 3 to 4 Years 4 + Years	What Classes Were Taken Previously?:

Are there any physical problems, past injuries or special needs that we should know about in order to better serve your child?

Please List TWO Emergency Contacts:

Contact 1 Name:		Contact 2 Name:
Contact 1 Phone:		Contact 2 Phone:
Relationship:		Relationship:

How did you hear about DANCE REFLECTIONS?:

(select one) Referral Walk-In / Drive-By Phone Book Web Site Link From Other Web Site Web Search Engine Mailer Other

I am aware that all tuition payments are due in full prior to the START of class. I am also aware that Dance Reflections takes every precaution to assure my child's safety. However, if an accident should occur and I cannot be notified, I authorize Dance Reflections to seek emergency treatment at my own expense. I will not hold Dance Reflections or any of its' staff members liable. I have read and fully understand the above written statements. ____________________________________     __________ Parent/Responsible Party Signature                 Date *(Parent must sign if student is under 18)

For more registration information please contact
Shelly Pershing - Owner/Director | 972-899-8010
2616 Long Prairie Road, Suite 107, Flower Mound, TX 75022

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