Dancer Name (Last, First, M)

Date of Birth/Age

Home Address

Home Phone (dancer)

Cell Phone (dancer)

E-mail Address (dancer)

Guardian name (Primary person responsible for dancer)

Home Phone

Home Address (if different from dancer)

Cell Phone

Work Phone

E-mail Address

Guardian 2 Name                             

Home Address

Home Phone

Cell Phone

Work Phone

E-mail Address

Insurance Provider

Policy or ID Number

Spotlight Studio of Dance does not carry medical insurance for its students.  It is required that all dance students be covered by their own family medical insurance policies, and if injury occurs it is understood that the student’s own policy is your only source of reimbursement.

Please sign below to acknowledge that you accept this policy                 Date

DAY & CLASS TITLE

TIME

Monday

Tuesday

Wednesday

Thursday

Saturday

Company     MINI    JUNIOR     TEEN   SENIOR

OFFICE USE ONLY

SMART TUITION

DATE PAID

DATE GIVEN

AMOUNT PAID

SMT. BEGINS

REG. FEE

CHECK #

DATE PAID

OFFICER SIGNATURE