Class Registration Little Leaps Dance With Me class

Class Registration

Dance With Me classes for Tykes & Tots 12-30 months (with a caregiver)
Parent/Guardian Info
Name*

First NameLast Name
e-mail*
Primary Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact (If Parent/Guardian cannot be reached)*
Relationship to Student*
Emergency Phone*

Area CodePhone Number
Please note: Parent/Guardian listed above assumes primary responsibility for payment. Tuition payment must be received via Venmo to Carrie-Smith-378 in order to reserve your place in the class. If payment is not received 24 hours before the first class, your registration will be canceled.
Student Info
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Add Student 2?

Add Student 2
Student 2 Info
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Age
Class Selection

All programs are designed for Tykes & Tots 12-30 months (with a caregiver)
- Tuition is $12 for one class or purchase a 4-class pass for $40
- 10% discount on classes and class packages for additional children 6-24 months. Discounts can't be combined. The higher discount will apply.
- Siblings 31 months and older are welcome to attend at no additional charge.

Student 1: Tykes & Tots, 12-30 mos. 4-class Pass "Dance With Me"$40.00

Valid for Dance With Me classes, Mondays 10:00am at DivaDance Port City, 2152 Wrightsville ave, Wilmington.

Student 2: Tykes & Tots, 12-30 mos. 4-class Pass "Dance With Me"$40.00

Valid for Dance With Me classes, Mondays 10:00am at DivaDance Port City, 2152 Wrightsville ave, Wilmington.

Student 1: Tykes & Tots, 12-30 mos. Single Class Monday or Thursday$12.00

Mondays 10:00am at DivaDance Port City, 2152 Wrightsville ave, Wilmington.

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Student 2: Tykes & Tots, 12-30 mos. Single Class Monday or Thursday$12.00

Mondays 10:00am at DivaDance Port City, 2152 Wrightsville ave, Wilmington.

QuantityClass Date
Item subtotal:$0.00

Enter coupon

Total $0.00

Totals

Multi- student discount will be applied after form submission. Our office will email you a confirmation with final total including this discount if applicable. Discounts can't be combined. The higher discount will apply.
Tuition payment must be received via Venmo to @Carrie-Smith-378 in order to reserve your place in the class. If payment is not received 24 hours before the first class, your registration will be canceled. Class sizes limited.
Notes:
Terms and Conditions
Today's Date

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Date
By electronically signing below, I agree to the following: I understand that the risk of injury or illness is inherent in dance and I fully understand and accept these risks. I realize that while Little Leaps endeavors to take reasonable and appropriate safety precautions, participation in supervised lessons and events involve some risk of injury and/or illness. I hereby release and hold harmless Little Leaps and all of its principals, agents, contractors, and employees of and from any liability, actions, claims, and damages of any kind, on account of injuries of any type or nature incurred in connection with my child’s participation in this program. In case of a medical emergency where I am not immediately available, I authorize Little Leaps staff to take all actions reasonably necessary to preserve and protect the health of my child. I give my permission for Little Leaps to attain emergency medical treatment for my child if I cannot be reached.You also give your permission for the public display of any Little Leaps visual images that your child may appear in. By typing my name below, I am signing this agreement electronically. I agree this electronic signature is the legal equivalent of my manual signature on this agreement. PARENT/GUARDIAN FIRST AND LAST NAME BELOW.
I Agree
Parent/Guardian E-Signature*

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Class Registration

Parent/Guardian Info

Student Info

Student 2 Info

Class Selection

Totals

Terms and Conditions