ZOJA Dance Studio Inc.

2007/2008 Fall Registration Form

Student’s Name___________________________________________________________________________ New Student

Address_________________________________________________________________________________ Change of Address

City ___________________________________ State _______ Zip Code ___________________________________________________

Parent or Guardian___________________ Alt. Emergency Contact____________________ Relation______________________________

Home Phone ( ) ____________ Business Phone ( )_______________ Emergency Contact Phone ( )____________________________

Cell Phone ( ) _______________ School_________________________ Grade______ Date of Birth______________________________

Previous Dance Experience Yes No If yes, where? _____________________ How Long? _____________________________

How did you hear of us? Newspaper Flyer Phonebook Referral Other ____________________________________

Please list classes below

Class 1_________________________________________________________________________________________________________

Class 2_________________________________________________________________________________________________________

Class 3_________________________________________________________________________________________________________

Class 4_________________________________________________________________________________________________________

Dance Class Tuition Total classes @ $85.50 ________ Discounts 10% Mult. Class/family ________ 15% Full Year ________ Registration Fee Fall $10.00 ________ Tuition Total ________ Check #_______ Cash Receipt# _______ MC/VISA # ____________ Exp. _______ Date _____________ Int. _________

OFFICE USE ONLY 2nd Session Payment ________ Check #______ Cash Receipt# _______ MC/VISA # ______ Exp. ____ Date __________ Int. _______ 3^rd Session Payment ________ Check #______ Cash Receipt# _______ MC/VISA # ______ Exp. ____ Date __________ Int. _______ 4^th Session Payment ________ Check #______ Cash Receipt# _______ MC/VISA # ______ Exp. ____ Date __________ Int. _______

I am going to be in the May Recital and understand there is a costume fee. I am not going to be in the May recital. _____

Please list any medical condition or special needs of child ________________________________________________________________

I understand and agree that ZOJA Dance Studio Inc. and all instructors employed therein disclaim any and all liability with regard to personal injury and/or loss, damage, or theft of personal property while on the premises of the studio. I have (dancer enrolled in classes) had no mental or physical conditions in which dance class would be against my doctor’s recommendations. I have received a copy of the ZOJA policies and accept all terms. I agree to comply with the student policies, dress code, and tuition. I understand that I will be held responsible for all tuition payments upon registration, and will be assessed a $10.00 late fee every month if my balance is 30 days past due, until paid in full. Balances over 90 days will incur an 18% finance charge annually. Class sizes are limited. Registration for the following session will not be accepted until all prior tuition payments are paid in full. Tuition and Costume fees are absolutely non-refundable. I hereby grant ZOJA Dance Studio Inc. permission to photograph my child and use for promotional purposes. I understand that this is a legal and binding contract.

Signature (Parent or Guardian if under 18 years) _____________________________________________________