REGISTRATION FORM

To register, please print this form and mail with payment to:

American Dance Institute
8001 Greenwood Avenue North
Seattle, WA 98103

Pre-Registration Dates:

Summer 2010:
Returning Students, May 4 - 8, 2010
New Students, May 9 – June 5, 2010

Student’s Name:

Parent’s Name (if student is under 18):

Mailing Address:

ZIP:

Email Address:

Phone - Home:

Student's Date of Birth:

Phone - Work:

Emergency Contact:

Phone - Cell:

Emergency phone #:

Check one: Returning Student New Student

If new student, how did you hear about us? ____________________________________________________________________________

Class(es) Wanted (include days and times):

Please describe any physical limitations of student and list any serious past injuries.

I agree to participate/let my child participate in the programs of American Dance Institute, and hereby release American Dance Institute, its owners, instructors and employees form liability for any injury I/my child may suffer as a result of my/their participation. I have read & understand the tuition, refund & missed class policies.

Signature:

Date:

Payment enclosed for (please check one):	Full Semester, Pre-Paid in Full	$
5% Early Bird Discount for Full Session paid before June 6, 2009		$ -
	Drop In / Class Card Fee (Open Adult Program)	$
	Annual Registration Fee	$ 15.00

Check Enclosed

Total Paid:

Thank You!