To register fill out this form and mail with payment to: 16 Western Ave. Auburn, Me. 04210

Student's name(s) _____________________________________________

Birth date____________________________ age_____________________

Parents name_________________________________________________

Address_____________________________________________________

City_____________________________State_____Zip________________

e-mail address_________________________________________________

Tel. day_____________________ evening__________________________

Physical or learning difficulties_____________________________________

___________________________________________________________

Dr. names and tel.______________________________________________

Class________________________________________________________

Time(s)______________________________________________________

Day(s)______________________________________________________

 (please list all classes/days/times)  ( please fill out reg. form for each student).

 Reg. Fee:                $    10.00         

Tuition for classes: $                       

Total amount paid:$                      

                    ****Registration is required*****

Waiver of liability: I agree that I will not hold The dance Center or any guest teacher or employee liable for injuries or illness contracted by the student while at The Dance Center. In the event of an emergency, I give The Dance Center permission to get treatment for my child. Allow the Dance Center to take pictures during dance class.

________________________________________Date_____________
Signature of parent or guardian required. (If 18 or older student's signature)