EDC Fall Registration Form (PDF)




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Title: Microsoft Word - Summer Registration Form 2016.doc

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FALL SESSION 2016-2017
STUDENT REGISTRATION
FORM

178 Stelton Rd. Piscataway NJ 08854
(732) 856-1156
Admin@evolutiondancecenter.com
evolutiondancecenter.com

Student: Last Name

First Name

Age:

Date of Birth:

/

Address: Street

City

Home Phone

Cell Phone

/
Zip

Parent's Name (First & Last)

Work Phone

Parent's Name (First & Last)

Work Phone

♦Email Address for Weekly Newsletter & Studio Updates – You may include 2 email addresses. Please print clearly

♦Emergency Contact Information (Other Than Parent)
Name

Phone

Relation to Student

♦Student Medical History: Please list any previous injuries, allergies, handicaps or disabilities. It is important for our staff to be prepared and
aware of any hindrance to your child’s performance in class.

♦I agree to provide medical insurance for the above named student and will not hold Evolution Dance Center or its agents or employees
liable in the event of any accident of injury. If I am not reached in an emergency, I give my permission to the staff to render or act in my
behalf to obtain emergency medical treatment for this student for any illness or injury that may occur while attending Evolution Dance Center.
♦Publicity Release
I agree and authorize the use of the student's name, pictures and voice to be used on films and media for promotional use. I give my
permission for Evolution Dance Center to use and publish these materials for publicity and advertising with no expectation of compensation.

Parent/Guardian Signature
Please List Previous Experience
How Did You Hear About Us?
♦Class Registration for Fall 2016-2017
Classes

For Office Use Only
Tuition________ + Misc.____________= Total________ Payment
Received: Cash_____ CC Type_____ Check #___________
Tuition for ______amt of classes: $______________

Day & Time

Date of Registration: ___________
Registered by:_________________






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