*Student Name:
*Parent Name:
*Address:
Email:
Please check if you would like to receive studio information by email.
*Phone:
* Student's Birthdate:
*School / Grade as of Sept 2012:
Classes Registering: (please indicate times of classes)
Previous Dance Experience / Where
Referal
Internet / Online
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Direct Mail
Other
How Did you hear about us?
Payment:
$30 Registration Fee
I have read and agree to the terms and conditions stated below.
FALL REGISTRATION 2011-2012
You can enroll your child for dance classes by filling out this form.  After you submit your form,
you will receive a confirmation email withing 24hrs.  After you hit submit, you will be taken to a
secure site for payment.  $30 non-refundable registration fee is due at time of enrollment.
I hereby consent to participating in dance/yoga classes at Saucon Valley Dance Conservatory (SVDC).  I do hereby agree to indemnify and save
harmless SVDC, it’s instructors, members and authorized guests, as well as its agents and employees, of and from any liability of any nature or kind
whatsoever arising out of or in any way connected with any claims or demands made by or on behalf of the participant.
I have read and understand the terms of this consent and indemnification as set out above.  By checking the 'agreement box' above, I agree to the
terms stated above.