2010 Summer  Registration

3-6 Year Olds, 7-9 Year Olds

 

 

 

 

Child’s Name:___________________________________Age:____________Birthdate:_____/_____/_____

 

Parent’s Name:______________________________________Email:_______________________________________

 

Address:________________________________________________City:_________________Zip:________

 

Phone:______________________Work Phone:__________________Cell Phone:_____________________

 

Special Health Concerns:______________________________________________________________________________

 

I hereby release and discharge Grayson School of Ballet, its successors, directors, officers, employees and agents from any and all liabilities, claims, lawsuits, losses, costs, causes of action and damages of any kind originating or in any way arising from my/my  child’s  participation.  I  hereby declare that the terms of this  Release have been completely read, are fully understood and are voluntarily accepted for the purposes of my/my children’s participation in the activities of the Grayson School of Ballet

 

Please enroll my child in:

              3-6 Year Olds                                                        7-9 Year Olds

June       _______                                                                 June       _____

    Nonrefundable $35 Deposit Enclosed , Check #_____                                        Nonrefundable $95 Deposit Enclosed , Check #_____

July       _______                                                                 July       _____

       Nonrefundable $35 Deposit Enclosed , Check #_____                                     Nonrefundable $65 Deposit Enclosed , Check #_____

 

 

Please bill my credit card:

 

 

 

 

 

 

 

 

 

 

 

Parent Signature:________________________________________________________Date:______________________

 

 

Total Amount Enclosed:      $_________________

 

Please charge $______________ to  my:

Visa ____ Discover____MasterCard_____

Card Number:_____________________________

Security Code:_________

 

Signature:___________________________________________