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STEPPIN’OUT 2021-2022 FALL REGISTRATION FORM


Parent 1 First Name:__________________________ Last Name:_____________________________________

Phone 1:______________________________________ Phone 2:_____________________________________

Mailing Address:_____________________________________________________________________________

Email Address:__________________________________________________________________(for studio newsletters)

Parent 2 First Name:__________________________ Last Name:______________________________________

Student #1 First Name:________________________ Last Name:______________________________________

Birthdate: __________________________________ Age:_______________________________________

Student #2 First Name:________________________ Last Name:_________________________________

Birthdate: __________________________________ Age:_______________________________________

(ADDITIONAL STUDENTS PLEASE USE BACK OF REGISTRATION FORM)

PLEASE LIST CLASS/CLASSES STUDENT/STUDENTS WILL TAKE

Student # Class Name Day & Time Instructor

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Medical Conditions or Allergies:____________________________________________________________________

Registration Fee Enclosed:$_______________ September Tuition Enclosed:$_____________


I am responsible for fees for all services rendered. I have read and understand the tuition policy for dance and aerial classes. I

agree to allow Steppin’Out Dance Academy, Corp. to automatically charge my credit card for any balances or fees that are past

due on my acct.


I understand that I will receive a $10 charge if my card on file is declined a second time. In consideration of the benefits derived

from Steppin’Out Dance Academy, Corp., I (we) do hereby agree to hold harmless the Steppin’Out Dance Academy, Corp., it’s

agents or employees for any and all claims of personal injuries to myself, my (our) daughter(s)/son(s)while participating in

said dance, aerial, fitness, or other activities on the premises.

I understand that photos and videos may be taken throughout the year, and these images may be published or used for

advertisement or promotional purposed by Steppin’Out Dance Academy, Corp, and it’s agents. I relinquish my right to protest

any such use, or receive compensation of any type.


CREDIT CARD TO KEEP ON FILE:_______________________________________ EXP. DATE:____

(required)

*I elect to have my monthly tuition fees automatically charged to the card on file: Yes:___ No:____


Parent or Legal Guardian Signature:_________________________________________ Date:__________

Please Print Name:_____________________________________________________________________________


Student # _             Class Name_               Day & Time_             Instructor_

________________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

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