Elite Dance Co.
Registration Form
Student First Name: ___________________ Student Last Name: _____________________________
Parent First Name: ____________________ Parent Last Name: ______________________________
Address: Email Address: _____________________________________
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City: _____________ State: ____ Zip: _________
Home Phone: _____________________________
Work Phone: ______________________________
Cell Phone #: _____________________________
Child’s Birth Date: _________________________
Emergency Contact Name: _________________________________ Phone: _______________________
Please list below any health issues your child might have:
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Monthly Class Tuition:
1.0 Hour $40.00 2.0 Hours $70.00 3.0 Hours $90.00
1.5 Hours $60.00 2.5 Hours $80.00 3.5 Hours $100.00
Monthly/Quarterly tuition is due by the 10th to avoid a $10 late charge per monthly billing period.
**Please indicate whether you would like to be billed **MONTHLY** **QUARTERLY**
(Quarterly accounts receive 5% discount-not applicable to monthly competition dues)
To reserve your child’s spot in an available class, please return this registration form and $25.00
registration/insurance fee to: Elite Dance Co.
1919 Industrial Drive #400
**Registration/Insurance Fee is NON-REFUNDABLE** Liberty, MO 64068
Class Name/Type Day Time Class Length
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We understand that activity involving excessive motion can cause accidental injury. In compliance with the registration
into this dance program, we agree to indemnify ourselves to pay for any and all treatment incurred with activities
concerning the dance and tumbling program along with any traveling performances, including Elite Dance Co.
Our primary session follows the standard school year, September through June. If removal of your child from their
enrolled class is necessary, we do ask for a 30 day written notice. Because of our limited class sizes, if a 30 day
notice is not provided, you are responsible for 30 days of class tuition from your removal date.
Parent Signature: _____________________________________________ Date: _________________
Individual Responsible for statement billing
Name: __________________________________
Address: ________________________________
SSN: __________ - ________ - ____________
Drivers License Number:
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