Charlotte Dance Instruction LessonsEnrollmentForm

HOW DID YOU HEAR ABOUT US?

STUDENT NAME (Last)

(First)

STUDENT DATE OF BIRTH (Month) (Day) (Year)

ADDRESS:

CITY STATE ZIP

PHONE# CELL #

E-MAIL ADDRESS

MOTHER’S NAME WORK #

FATHER’S NAME WORK #

EMERGENCY CONTACT CONTACT #

PERSON RESPONSIBLE FOR ACCOUNT

PREVIOUS DANCE SCHOOL (if any)

DANCE EXPERIENCE (Years/Level)

ACADEMIC SCHOOL GRADE

855 SAM NEWELL RD. SUITE #205

MATTHEWS, NC 28025

Address CHANGE as of 8.1.2010

12210 Copper Way, Suite 230, Charlotte NC 28277

"Ballantyne Area"

Please call the studio for additional information or questions

(704) 841- 7762 or (704)-208-6221 *8am-9pm weekdays & weekends

REGISTRATION/ENROLLMENT FORM 2010-2011

Please complete the following information by using your "Tab" key to move through the form. Please do not hit ENTER or the SUBMIT button until you have completed the form. A CDC representative will contact you to complete the registration process. Payment is accepted online (click on " Pay Registration Fee now " below) or may be made in cash, by check /credit card by stopping by the studio, by mail, or by speaking with a Carolina Dance Capital representative. Registration fee is $50 per dancer.

If you do not like to submit online, you have the option to download the Registration Form and bring it to the studio. To do this, click on below. Thank you

Please print out the Policy/ Release Form to be signed before attending any classes. You may also stop by the studio to receive, complete and sign the form.