Registration Form  FALL/WINTER  SESSION  2023-24

Student Name_________________________________________________Birthdate___________________

Address________________________________________________________________________________

City___________________________________________Zipcode________________

Mother's Name_______________________Father's Name_____________________

Home Phone_________________________Work Phone_______________________

Any medical problems?__________________________________________________
____________________________________________________________________

(I understand that On Your Toes Dance Studio and  staff will assume no
responsibility for injuries or medical expenses incurred by my child. My
child has no physical, mental or emotional condition which would interfere
with participation in this program.)

Parent/Guardian Signature________________________________________ Date____________________

Per Class Tuition Rate_______________________________

** A $25  fee will be charged for any returned check

Requested Class ___________________ Day_________ Time_________