REGISTRATION FORM - SUMMER/FALL 2019/20                  

DATE:___________________________________ 

NAME:______________________________________________________________  

ADDRESS:___________________________________________________________

EMAIL:_____________________________________________________________

CONTACT PHONE NUMBER:______________________________________________

DATE OF BIRTH:_______________________________     AGE:________________

PARENT(S) TO CONTACT:____________________________________________________________

TEEN EMAIL:_________________________________________________________

MEDICAL CONCERNS/ALLERGIES:_________________________________________

____________________________________________________________________

PLEASE REGISTER FOR THE FOLLOWING CLASS(ES)

CLASS/DAY/TIME                                                                                                 COST

_____________________________________________________________$

_____________________________________________________________$

_____________________________________________________________$

                                                                                  SUB TOTAL                  $ 

REGISTRATION FEE:  $16.00 INDIVIDUAL      $28.00 FAMILY                           

                                                                                  TOTAL                          $                                                                                                             

FORM OF PAYMENT:  CHECK                     VISA/MASTERCARD

VISA/MASTERCARD NUMBER:_________________________________________________________   EXP. DATE:_________________

PLEASE REMIT WITH PAYMENT IN FULL TO:  DANCE UNLIMITED, 1415 HANOVER STREET, HANOVER, MA  02339, CALL STUDIO (781) 871-4264 OR EMAIL This e-mail address is being protected from spambots. You need JavaScript enabled to view it                        USE BACK SIDE IF NECCESSARY