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, printed form in person along with a registration fee check to Dance Reflections (Fall fee: $30; Summer fee: $20). This registration cost is a, non-refundable fee. Please make checks payable to Dance Reflections.
Dancer's Name:
    Age:
Address:
    Birth Date:
City:
Zip:
Home Phone:
Parent or Guardian Name:
Cell Phone:
Work Phone:
Email Address:
 
Has student danced previously?: (select one) How Long?: What Classes Were Taken Previously?:
How did you hear about DANCE REFLECTIONS?:
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:
For FALL: I am aware that all tuition payments are due in full by the FIRST DAY of each month and NO LATER THAN THE EIGHTH. A $10.00 LATE FEE will be incurred for payments made after the close of business on the 8th.    For SUMMER: I am aware that tuition payments are due prior to the start of the session(s). 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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