Print and Return completed form with $25 fee to Cabarrus Dance Academy at 

2810 Poplar Tent Road,        Suite 100       Concord, North Carolina        28027

Student Name __________________________Birthdate_____________

Address________________________________Zip Code____________

School_________________________________ Grade (fall 08)________________

Home Phone Number___________________E-Mail Address________________________________

Dance Experience____________________________________

Limitations/ Health Problems/ Allergies________________________

Indicate Class or Camp for Enrollment :________________________________________

Name of Responsible Adult ________________________________________

Address (if different)_______________________________________________

Emergency Contact & Phone_________________________________________

I understand that the Cabarrus Dance Academy does not carry medical insurance for students.  The school  will not be held responsible for injuries, accidents, or lost articles.  The registration fee holds my child's space and is non-refundable.  The full tuition payment is due at the the first lesson.

Signature of Responsible Adult__________________________________________________________________________

How did you hear about us?  (Newspaper, Yellow pages, Internet, Referral?)

If a referral, list her/his name here ___________________________________________________________________________

For office use only

Account # _____________________________# of Sudentst_________ Medical Code______

Payment Plan __________________________ Registration Fee_______

Check/ Cash/ Credit/                Date_______________