EDC Summer Registration Form (PDF)

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Title: Microsoft Word - Summer Registration Form 2016.doc

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178 Stelton Rd. Piscataway NJ 08854
(732) 856-1156

Student: Last Name

First Name


Date of Birth:


Address: Street


Home Phone

Cell Phone


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)


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 Summer 2016

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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