Registration

Please complete this form and return with your registration fee (non-refundable) for each student to:

 482 Ring Rd, Carthage, NC 28327

Checks should be made payable to “Dori’s Studio of Dance and Music.” Please put student’s first and last name on check.

Student’s Name________________________________________________________

Address_____________________________________________________________

City_____________________________________State______Zip_______________

Phone_________________ Cell:______________ Email Address___________________

Date of Birth__________________________Age____________________ School______________________________ Grade___________________

Previous number of years at Dori’s (Not counting coming year)________________________

Mother _____________________________________________________________

              Name                      place of employment work phone

Father ______________________________________________________________

             Name                 place of employment work phone

I, the undersigned, fully understand and agree that the organizers, owners, or instructors shall be free from any liability of claims arising by reason of any injury or illness at Dori’s Studio of Dance and Music. Permission is hereby granted to transport my child to a doctor or hospital in case of illness or injury, when unable to locate parent.  I further give permission for Dori’s Studio to publish photos of my child in conjunction with the studio’s needs.

Parent’s Signature__________________________Date_________________________

Person to contact (other than parent) in case of emergency:

Name________________________________________________________Phone_____________________

Doctor_______________________________________________________Phone_____________________

PLEASE CIRCLE DESIRED CLASSES.

The Music Class          Monday 10am or Thursday 10am

Tiny Tots Dance          Tuesday 10am or Wednesday 4:30

Preschool Dance         Tuesday 9 am, Tues 6:00, Wed 5:00, Thurs 4:15 or Sat 10:00am

Beginning Dance         Monday 4:00, Tuesday 1:00, Wednesday 5:45, or Saturday 9am

Elementary Dance      Tuesday 4:00 or Saturday 10:45

Senior Dancers            Ballet Monday 5:00-6:00     Hip Hop Monday 6:00-7:00

                                    Tap Thursday 5:00-6:00            Jazz Thursday 6:00-7:00           

Theatre                        Friday & Saturday afternoons TBA beginning September 18th

Piano Lessons             Call for Schedule

Company Dancers must take ballet to go to competition.         

         

Sign up for our preauthorized payment service from your debit or credit card:

Credit Card Type (check one): VISA        MC

Credit Card #_______________________________________ Exp. Date___________

Signature_____________________________________________________________

Remember to pre-register NOW to be assured of getting the class time you prefer before classes fill-up!

Office use

Date_________________                Amount Paid_________       Check #______________

Cash_________________                MC_____ VISA______