REGISTRATION FORM 2021-2022

Registration forms can be mailed, emailed or dropped off at Studio. All students must pay a $25
registration fee. Please make checks payable to Jacqueline Blankenburg and send to: Jacqueline
Blankenburg/JDS, 20 Madison Road, Halifax, MA 02338.

Student #1

First Name: ___________________________ Last Name: ______________________________

Gender: __________ DOB:__________ Grade Level:__________

Any allergies, if so, what:

_____________________________________________________________________________

Class(es) day and time:

_____________________________________________________________________________

_____________________________________________________________________________

Student #2

First Name: ___________________________ Last Name: ______________________________

Gender: __________ DOB:__________ Grade Level:__________

Any allergies, if so, what:

_____________________________________________________________________________

Class(es) day and time:

_____________________________________________________________________________

_____________________________________________________________________________

Contact #1

First Name: ___________________________ Last Name: ______________________________

Home Phone #: ________________________ Cell Phone #: ____________________________

Email: _____________________________________________
Address:

________________________________________________________________________

________________________________________________________________________

Contact #2

First Name: ___________________________ Last Name: ______________________________

Home Phone #: _________________¬¬¬¬_______ Cell Phone #: ____________________________

Email: _____________________________________________

Address: ________________________________________________________________________

________________________________________________________________________________

Please check the following upon agreement to the statements below.

____Registration Fee

A $25 registration fee is due for each dancer upon registering for classes. Payment can be made in the
form of cash or check only. This is non-refundable.

____Payment Policies

Tuition must be paid the 1st week of every month in the form of cash, check or Venmo. Tuition is non-
refundable. If not paid by the 10th of each month, there will be a $5 late fee charged for each week
tuition is late.

____ Release of Liability

All students attending class at Jacqueline’s Dance Studio do so at their own risk. Owner and Instructors
are not liable for damages resulting from personal injuries sustained by the students on the premises.

____Dance Attire

All Students shall wear proper dance attire during dance class. I understand that wearing improper
attire will prevent me from participating in that dance class.

____Recital Costumes

All students are responsible for purchasing a costume(s) for our annual recital. Costumes and recital t-
shirts are $95.00. All combo classes will be $125.00. Any additional costumes will be $85.00. All
costume payments are due by November 15, 2021. Costume fees are non-refundable.
____Photo/Video Release (NOT required)

I give Jacqueline's Dance Studio permission to take pictures and videos of my child to be used for
advertising purposes.

___________________________________

Name (Print)

___________________________________

Signature

_________________

Date