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2464 W. 12600 S.

Suite 160
Riverton, Ut 84065

Registration Form

Child’s Name___________________________________
Current Age_______ Birthday ____________M or F
Parent’s Names_________________________________
Street Address__________________________________
City_______________ State_______ Zip Code________
Home Phone_____________ Email__________________________
Mother’s Work Phone_____________ Mother’s Cell _______________
Father’s Work Phone ______________Father’s Cell Phone___________
Emergency Phone Number ____________Relationship______________
Medical Information/Conditions________________________________
Special Family Situations______________________________________

Registration Fee $ 25.00 per student, $15.00 each additional child.

$30.00 Preschool Materials Fee
$20.00 Dance Activity Fee

Credit Card Policy

We require additional security of a major credit card for each student’s account. This will
only be used for those accounts that are overdue or for those that sign up for automatic
billing. By signing below you are agreeing to the following:
1. Any tuition that is not paid for by the 10thor the month, in which it is due, will be
billed to your credit card along with a $10.00 late fee.
2. Any costume, extra practice, recital fee, etc, will be charged to your account if not
paid by the due date. A $5.00 late feewill also be charged to your account.
Parent Signature ______________________________________________________
____ Master Card ____Visa____ Discover Card____
Credit/Debit Card________________________ Expiration Date_____

I wish to enroll my child, _____________________________________,

in Vision Dance and Learning Center, I give permission for my child to participate in school activities and will not
hold the school responsible for any injuries or accidents that may occur during school hours. I agree to pay tuition
by the first week of every month. I understand that I will not get credit or reimbursement from the school for days
missed. Teachers are subject to change.
Parents Signature_______________________________________________
I am registering for
For Office use only _______________________________
Payment taken by________