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REGISTRATION


Download a: PDF Registration Form
Fax completed form to 480-990-8531

or email to:pat@pssod.com



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Tuition payable to Pat Smith

 

Parent s Last Name________________________Parent's First Name_______________________________

 

Home Address__________________________________City____________Zip______

Email Address__________________________ Cell Phone___________________________

Work Phone___________________________ Home Phone____________________________

 

1st Student s Name______________________________Age____D/O/B___/___/___


Class name_________________________________________Day____________Time__________________________


Class name_________________________________________Day____________Time__________________________

 

2nd Student s Name_____________________________ Age____D/O/B___/___/___


Class name_________________________________________Day____________Time__________________________


Class name_________________________________________Day____________Time__________________________


3rd Student s Name
______________________________Age____ D/O/B___/___/____


Class name_________________________________________Day____________Time__________________________


Class name_________________________________________Day____________Time__________________________

 

Name of Elementary/Middle/High School and release time for each student__________________________________________

 

Comments (interest, experience, concerns,etc.)_________________________________________________________________

 

How did you hear about Pat Smith School of Dance? ____________________________________________________________

 

 

Check interest in the following classes/workshops: ٱIrish Step ٱTap ٱBreak Dance ٱMat Pilates
ٱTumblingٱHula ٱCaribbean ٱFlamenco ٱMiddle Eastern ٱYouth Ballroom ٱAdult Ballroom
ٱKids Yoga ٱMusical Theatre

 

 

Photo Release: Pat Smith School of dance has my permission to display photographs of my child/children,

_____________________________________________________ on promotional flyers, web sites, schedules, and press releases.

Parent Signature _____________________________X

 

Release, Indemnity, and Assumption of Risk: I recognize the risks of illness and injury inherent in any exercise or dance program, and my child/children: _________________________________________________ is/are participating with the express agreement and understanding that I am waiving and releasing Pat Smith School of Dance from any and all claims, except for illness and injury directly resulting from gross negligence or willful misconduct on the part of the School.

Parent Signature ______________________________X

Return this form with tuition and $25 registration fee made payable to Pat Smith. Check#______Date___/___/___Amount______

 

More info: (480) 946-9269 or pat@pssod.com