Client Registration Form YOUTH (edited 2118)

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NEW CLIENT REGISTRATION

Class Style: ________________ Division: ___________________ Day: __________________

First name: ________________________ Last name: ___________________________

Birthday: __________________________ Gender: ______________________________

Phone: ____________________________ Email: ________________________________

Address: ________________________________________________

________________________________________________



EMERGENCY CONTACT INFORMATION

PARENT INFORMATION

Name:_________________________________

Name:___________________________________

Relationship to Student:_________________

Relationship to Student:____________________

Phone:________________________________

Phone:___________________________________

Email:_________________________________

Email:____________________________________

Date of Birth(OPTIONAL):___________________

NOTES:

PAYMENT AGREEMENT

I understand that Lisa Renee’s Dance and Enrichment Studios (The Studios) uses an Autopay system. I understand that my account balance will be pro-rated from the day that I/my child starts classes. I understand that The Studios will keep my card on file and my account will be automatically deducted the agreed upon amount on the first of every month. I understand that if for any reason I wish to cancel my payment contract, I must inform The Studios before the first of the following month and I will not be deducted for the following month. I understand that if I fail to inform The Studios of a contract cancelation before the first of the following month, then I will be deducted the originally agreed upon amount for that month. I HAVE READ THIS DOCUMENT AND UNDERSTAND IT.

______________________________________________ Name of Participant (Please Print)

______________________________________________ Name of Parent/Legal guardian (Please Print)

______________________________________________

_______________

Signature of Participant (18 years or older) or Parent/Legal guardian

Date Signed