Student Information:

First name:

Last name:

Address:

City:

Zip Code:
City:

State:
Gender:
Age:
Date of Birth:
Home Phone:

Cell Phone:

Email:
Allergies or Medical Problems:

School Attending:
Release Time from school:

Account Billing Information: (Parrent/Guardian)

First Name:

Last Name:

Street Address:
City:
State:

Zip Code:

Phone Number:

Cell Phone:

Email:

Place of Employment:
Work Phone:

Alternative/Emergency Contacts

Name of Parent #2:

Phone Number:

Place of Employment:

Work Phone:

Emergency Contact Name:

Emergency Contact Phone:

Enrollment

New Student Returning Student
# Years of training:

Please select the classes you would like to enroll into

Mommy/Daddy and me (Ages 2-4)
Ballet / Tap (Ages 3-5)

Ballet / Tap / Hip Hop (Ages 4 - 6)

Ballet (Ages 6 & up)

Pointe (at teachers discretion)

Jazz (recommendation 1 ballet class)

Hip Hop (Ages 6 & up)

Tap (Ages 6 & up)

Musical Theatre (Ages 8-11 and 12+)

Acrobatics or Gymnastics (Ages 8 - 1 and 12+)

African
Cheer Dance

All Boy Hip - Hop

Family Hip Hop

Irish Dance

Best Days that you are available for classes:

Monday
Tuesday

Wednesday
Thursday
Friday
Saturday

Days you are NOT available for classes:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

How did you find out about Agnes Stecker Dance Studio?

Parents/Guardians Please Read the Following Carefully! Enrollment is for September 2011-June2012. Any changes in enrollment must be submitted in writing. We will hold placement in the class until such notice is given. If a class is missed without providing a change of enrollment you will be responsible for any charges to the account up to the date such notice/documentation is received by the office. It is YOUR responsibility to keep us informed…we have almost 300 students and cannot keep “track” of each individual. There are no cash refunds on tuition or missed classes. Tuition Payments are due by the 1st of each month. Any balances on accounts after the 15th of the month will be charged a $20.00 late fee. Balances can not exceed $150.00 to continue with dance. Billing discrepancies need to be addressed with the office within 60 days from date incurred. Costume charges are in addition to tuition and will be paid in advance of receiving the costume. Costumes are ordered early in the dance year to insure a good selection, the full cost is your responsibility, whether the student continues with the class or not. Costumes are non-returnable/non-refundable. Please understand that by signing this document you are accepting the Terms & Conditions as they are written in this document and agree to the guidelines/regulations of The Agnes Strecker Center of Performing Arts. If your account is not up to date, your child will not be able to continue with dance classes until payment is made!