Online Registration:

Please fill out thoroughly (one form submission per student). * Required information

*Student Name:
Age:
Birthdate:
*Parent's Name:
Home Address:
City, State, Zip:
Home Phone Number:
Business Phone Number:
*Email Address:
Person responsible for payment (if not same as above):
Emergency Contact Name :
Emergency Contact Phone :
Are there any medical conditions that we need to be made aware of? If so, please describe:
Name of Person(s), and relationship, authorized to drop-off and pick-up student from dance class(es):
Classes of interest:	Pre-Junior Ballet/Tap Combo ( 4-6) Ballet Hip-Hop (Ages 11 and up) Jazz Tap Acting for Stage and Film (Ages 9 & up or permission of instructor)
Returning student? :	Yes No
If not a returning student, how did you hear about Spirit of Soul?	Friend - Name: Pennysaver/Yankee Trader Ad Promotional card Other-Please Specify:
I have enrolled the above name student, in a program of strenuous physical activity through Spirit of Soul Dance Studio, Inc., and hereby affirm that the enrolled student(s) are in good physical condition, and do not suffer from any disability that would prevent or limit participation in this dance program. I hereby release Spirit of Soul Dance Studio (including the Artistic Director, Tracé Wilkins Francis, and any of her family or staff), from any liability now or in the future, including muscle strains, broken bones, knee/foot/lower back injuries, soreness or other medical problems, however caused, occurring before, during, or after participation in Spirit of Soul’s dance program, or any events/activities sponsored or organized by Spirit of Soul Dance Studio, Inc. By signing, I hereby affirm that I have read & fully understand and agree with the above waiver. * By checking the box to the left and submitting this form, I hereby affirm that I have read & fully understand and agree with the above waiver. * By checking the box to the left and submitting this form, I am indicating that I have read and understand Spirit of Soul’s policies and procedures and agree to follow them as documented.  I also agree that I am financially committing myself to making timely installments during the 2010-2011 dance season as follows: Payment Options (please check one box): per month through Auto EFT monthly drafts from your checking/savings account.       Please click here for the auto-debit authorization draft form Four installment payments (due: Upon Registration, November 6, 2010, January 8, 2011 and March 5, 2011) via check, money order, cash or       debit/credit card (PayPal) Semi-annual payments (due: Upon Registration and January 8, 2011) via check, money order, cash or debit/credit card (PayPal).   Parent/Guardian’s name:    Date: