SDC	Registration Form
Shelley's Dance Company Ltd.								2010-2011
1st Student:	Last Name:				First Name:
Birthdate:	Month:	Day:	Year:	Age:	Health Care #:
	School Attending:				Academic Grade:
2nd Student:	Last Name:				First Name:
Birthdate:	Month:	Day:	Year:	Age:	Health Care #:
	School Attending:				Academic Grade:
3rd Student:	Last Name:				First Name:
Birthdate:	Month:	Day:	Year:	Age:	Health Care #:
	School Attending:				Academic Grade:
Parents/	Mom:				Dad:
Guardian:	email address			Student's cell #
	Address:						Postal Code:
	Telephone:	Residence:		Cell:			Business:
		Residence:		Cell:			Business:
Please Notify:		In event of emergency:
Other Information		Allergies or Medical Alert:
Schedule of Classes:					Office Use Only
See attached schedule of classes								PAID
	PAID
Sept					Registration Fee		$25.00
Oct							$40.00
Nov
Dec					Yearly Fee
Jan						Discount
Feb
Mar
Apr
May
June
						Total Hours:
						Monthly Fees:
						Total Yearly Fee:
Conditions of Agreement
Termination of this agreement will be at the discretion of Shelley's Dance Company Ltd. and will require written notification to be
received at least 30 days prior to termination date.  This agreement is for the instructional period…							Sept 1, 2010 - June 30, 2011
The terms of this agreement as stated herein, are endorsed as follows:
x_______________________________________________					x _____________________________________
Signed by Parent/Guardian if student is under 18 years of age					for Shelley's Dance Company Ltd.