Jazz Tap Combo Dance Class Registration Form
Fridays, starting January 3, join us for a jazz/tap combo dance class with Jessica Umbleby!
Parent/Guardian Name
First Name
Last Name
Student Name
*
First Name
Last Name
Birth Date
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Gender
Male
Female
N/A
Parent E-mail
*
example@example.com
Mobile Number
*
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
In case of emergency, please notify (include name and telephone number):
Emergency Contact (Name and Phone)
Please list any physical limitations, special needs, or allergies:
I'd like to pay online:
Yes
No, I'll pay in person by check
No, I'll pay in person by cash
Class is $195 and must be paid in full by January 1
Child/Beginner (ages 6-11) 6:30-8:30pm Fridays
$
195.00
Subtotal
$
0.00
Tax
$
0.00
Shipping
$
0.00
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
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Expiration Year
2019
2020
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Additional Comments
I understand that these classes require physical activity and that injury may occur. I agree not to hold responsible Star Performance Academy, Be3, Airfast Heating & Cooling, Inc., Airfast Home Improvement, Inc., Directors, Instructors, Staff, or Board Members. A written consent is required if someone other than the parent or guardian is to pick up or transport the child. Parents must arrive within fifteen minutes after the end of a scheduled class or rehearsal to pick up child. Due to limited enrollment, I understand that I am committing my child (or myself) for the entire summer camp, class, or rehearsal session:
*
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