Umoja Dance Registration Form

Registration Form

STUDENT INFORMATION

Student Name*

Age*

Date of Birth*

MM/DD/YYYY

Gender*

Allergies*

If none, write N/A.

Physical Restrictions*

If none, write N/A.

PARENT / GUARDIAN INFORMATION

Parent / Guardian Name*

Parent / Guardian Address*

Street Address

Street Address Line 2

CityState

Zip Code

Parent / Guardian Email*

Email address that will receive class links, studio updates general information ***

Parent / Guardian Phone Number*

EMERGENCY CONTACT INFORMATION

Emergency Contact Name*

Emergency Contact Phone Number*

REGISTRATION SELECTION

When you select the number of classes, the total due at registration amounts will pop up.

Double check your number of payments (1, 3 or 6) AND student type (new student or returning student/family)

Class Selection (Select all that Apply)*

Number of Classes (Choose 1)*

1 Class2 Classes3 Classes

1 Class Selection

1 Class - 1 Payment - NEW Student - $9351 Class - 3 Payments - NEW Student - $338.331 Class - 6 Payments - NEW Student - $189.171 Class - 1 Payment - Returning Student or Family - $9301 Class - 3 Payments - Returning Student or Family - $333.331 Class - 6 Payments - Returning Student or Family - $184.17

2 Class Selection

2 Classes - 1 Payment - NEW Student - $15502 Classes - 3 Payments - NEW Student - $543.332 Classes - 6 Payments - NEW Student - $291.662 Classes - 1 Payment - Returning Student or Family - $15452 Classes - 3 Payments - Returning Student or Family - $538.332 Classes - 6 Payments - Returning Student or Family - $286.66

3 Class Selection

3 Classes - 1 Payment - NEW Student - $20503 Classes - 3 Payments - NEW Student - $7103 Classes - 6 Payments - NEW Student - $3753 Classes - 1 Payment - Returning Student or Family - $20453 Classes - 3 Payments - Returning Student or Family - $7053 Classes - 6 Payments - Returning Student or Family - $370

Women Drum Bi-weekly Class

3 Classes - 1 Payment - NEW Student - $4903 Classes - 3 Payments - NEW Student - $1903 Classes - 6 Payments - NEW Student - $115

Total Due at Registration

Select your Payment Option*

Please submit your payment AFTER you submit this form.

WAIVER /RELEASE

The participant agrees and understands that Umoja Dance Company carries insurance covering its legal liability. The participant accepts all risks of participating in a dance class. The participant will not make a claim against or sue the Umoja Dance Company or any of its officers or employees for injury or damage resulting from participation in the class. It is mutually agreed upon that the participant is considered to be in good condition to participate in the class.
The participant gives full permission for Umoja Dance Studio to use pictures or video from class and/or performances for advertising purposes. The participant understands that his/her name will not be used.
The participant has read the "Welcome Letter". The participant will adhere to the rules otherwise will face dismissal from the studio.
Link to Welcome Letter.
The participant understands: NO REFUNDS and NO EXCHANGES.
The participant understands Registration Fees are due at the time this form is completed.
The participant has read the Tuition Rates & Payment Information and agrees to comply with its policies. The participant understands that tuition is due on the first class of every month and that a $20 late Fee will be applied to any delinquent payments Tuition is required every month regardless of attendance. Monthly tuition paymetns may not be skipped because of non-attendance. NO EXCEPTION.

Parent / Guardian Signature*

Date