ANNEMARIE'S DANCE ACADEMY
ONLINE REGISTRATION FORM 2011-2012

Please note that the schedule for 2011-2012 is not yet available.
At this time, you are only registering for a class type but you need to register to secure a spot in that class.
Schedule will be online mid-July.
 
There is a non-refundable $29.00 Registration Fee ($47 max/family) -- Please make cheque payable to "Annemarie's Dance Academy".
Mail or drop off to 70 Centennial Rd, Unit 1B, Orangeville, L9W 1P9. Your placement in class(es) will be confirmed after your cheque is received.
If we need additional information we will call or e-mail you.

*** IMPORTANT: PLEASE fill in ALL applicable fields, even if you are registering a returning student! ***

Are you registering a returning student? YES   NO
FAMILY NAME (of child/children):  
Billing Name: [First] [Last, if different]  
Street Address:  
Town:      Postal Code:  
Home Phone #:
[Use format 999-999-9999]		  
E-Mail Address:
Parent Information: Phone#'s:
Mother:
 Home (if different from account #):
 Work:
 Cellular:
 Pager:
      
Father:
 Home (if different from account #):
 Work:
 Cellular:
 Pager:
Emergency contact:
[In case parents cannot be reached]
Emerg Contact Relationship:
Emerg Contact Phone#:

Annemarie's Dance Academy is not responsible for injuries occurred outside the dance class.
STUDENT #1:
First Name Last Name Female   Male
Date of birth: YYYY MM DD Health Card Number  
Please check off classes student is registering in:
       Kinder Rhythm [Age 3]     Jazz      Tap      Ballet      Acro      Hip Hop      Lyrical
Term Adult Class: Ballet Hip Hop Tap
STUDENT #2:
First Name Last Name Female   Male
Date of birth: YYYY MM DD Health Card Number
Please check off classes student is registering in:
       Kinder Rhythm [Age 3]     Jazz      Tap      Ballet      Acro      Hip Hop      Lyrical
Term Adult Class: Ballet Hip Hop Tap
STUDENT #3:
First Name Last Name Female   Male
Date of birth: YYYY MM DD Health Card Number
Please check off classes student is registering in:
       Kinder Rhythm [Age 3]     Jazz      Tap      Ballet      Acro      Hip Hop      Lyrical
Term Adult Class: Ballet Hip Hop Tap
STUDENT #4:
First Name Last Name Female   Male
Date of birth: YYYY MM DD Health Card Number
Please check off classes student is registering in:
       Kinder Rhythm [Age 3]     Jazz      Tap      Ballet      Acro      Hip Hop      Lyrical
Term Adult Class: Ballet Hip Hop Tap
How did you hear about us?
Current Student
Word of Mouth
Website Search
Newspaper
Flyer/Brochure
Advertisement (please specify)    
Other (please specify)    

Additional information:


THANK YOU!
Someone from Annemarie's Dance Academy will get back to you shortly.


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