MAKING A CHANGE PERFORMING ARTS COMPANY

REGISTRATION FORM

If you would like to register your child(ren) for classes please fill out the registration from

PARTICIPANTS NAME:
*
PARTICIPANTS DATE OF BIRTH:
*
AGE:
*
CLASSES REGISTERING FOR:
*
ADDRESS:
*
CITY
*
STATE:
*
ZIP:
*
HOME PHONE:
*
CELL PHONE
E-MAIL ADDRESS:
EMERGENCY CONTACT NAME:
*
EMERGENCY #:
*
SCHOOL ATTENDING:
*
MEDICAL CONDITIONS WE SHOULD BE AWARE OF:
*
I hereby agree not to hold MAKING A CHANGE PEROMING ARTS ACADEMY its director staff and any facility utilized by the company responsible for any damages or liabilities due to theft accident or injury during or resulting from my child's partisication in any capacity of or relating to any function or activity of the said MAKING A CHANGE PERFORMING ARTS ACADEMY. Payments for monthly classes and private lessons are due upon the first class of the month. There will be a 5 day grace period. Thereafter a $15.00 late fee per month will be applied to oustanding accounts. I hereby assume all financial responsibility for above student(s) enrolled at MAKING A CHANGE PERFORMING ARTS ACADEMY. I further understand that I will be charged for all classes until I have notified the academy of my or my child's withdrawal from classes. In the event it becomes necessary to refer this account for collection you (as the parent/guardian) will be reliable for all collection fees including attorney fees interest etc.
PARENT/GUARDIAN NAME:
*
PARENT/GUARDIAN NAME (THIS LINE SERVES AS A SIGNATURE):
*
DATE:
*
Security code:
*
Do not enter anything in this field:

* indicates a required field