The Movement Center
278 Great Road
Acton, MA 01720
(978) 264-4585
| | Download a Registration Form | | | Summer | | DOC | | | Fall | | DOC |
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PARENT 1 ______________________________
ADDRESS _________________________________________
CITY ____________ STATE ______ ZIP ________
HOME PHONE _____________ CELL PHONE _____________
EMPLOYER ____________________ WORK PHONE ____________
PARENT 2 _____________________ HOME PHONE ____________
EMPLOYER ____________________ WORK PHONE ____________
EMERGENCY CONTACT ________________________ PHONE______________
STUDENT NAME _____________________ BIRTH DATE ________ AGE_____
SCHOOL ____________________________ GRADE ______
MEDICAL /ALLERGIES _____________________________________________ |
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| CLASSES DAY TIME TUITION | | _____________________ | _______ | __________ | _________ | | _____________________ | _______ | __________ | _________ | | _____________________ | _______ | __________ | _________ | | _____________________ | _______ | __________ | _________ |
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REGISTRATION FEE _________
TOTAL _________ |
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| The undersigned assumes all responsibility for student injuries or damage that may occur while participating in activities or using dance studio’s facilities or following instructions in or out of the dance studio location. |
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| PARENT/GUARDIAN SIGNATURE_________________________________DATE_________ |
