Registration Form

Registration Date:
Account Number:
The Dance Studio of Union Parish
380 Bernice Hwy
Suite 3
Farmerville, LA 71241
318-548-2748

Billing Name
Address
City State Zip/Postal
Hm Phone
Wk. Phone
Parent 1 Hm. Phone
Parent 2 Hm. Phone
Private
E-Mail
Cell
Cell
Emergency
Contacts
Phone
Phone
Phone
Phone
Wk. Phone
Student Name
Address
Birthdate School Grade
Medical Info:
Dr. Name Phone
Classes Name Level Room Day Time Tuition
Registration Fee: Total Tuition:
City State Zip/Postal
E-Mail
Sex
I have received, read, understand, and agree with the registration information including Tuitions & Fees,
Attire, & Studio Policies. I agree that The Dance Studio of Union Parish shall not be liable in any way for
injuries sustained during classes or at any of its related functions and hereby release the studio and
employees from all liability for all personal injuries caused by, or arising from activities or activities related
thereto.
Parent Signature: Date: