MEDWAY DANCE AUTHORITY
R
EGISTRATION FORM 2020
One form per student please
STUDENT’S NAME __________________________________________     

PARENT’S NAMES __________________________________________

STUDENT’S BIRTHDATE ____________________________________  
         
ENTERING GRADE  ________   AS OF   SEPTEMBER  1,  2019

EMAIL____________________________________________________            

HOME PHONE #   ________________________    CELL PHONE # __________________________

STREET ADDRESS _______________________________________________________________  

TOWN ______________________________   ZIP CODE______________________

EMERGENCY CONTACT ___________________________________________

EMERGENCY CONTACT PHONE #___________________________________

RELATIONSHIP TO STUDENT
_______________________________________________________________


ALLERGIES/PHYSICAL LIMITATIONS
________________________________________________________________________________________________

IEP OR ANY INFO THAT WILL BE IMPORTANT IN TEACHING YOUR
CHILD________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

PHYSICIAN’S NAME_________________________________              PHONE________________________

PHYSICIAN’S
ADDRESS_____________________________________________________________________________________________________________

INSURANCE COMPANY _______________________________________________

POLICY NUMBER____________________________________________


PREVIOUS DANCE EXPERIENCE:

DANCE SCHOOL ___________________________________________YEARS ____________________

TYPES OF
DANCE_______________________________________________________________________________________


PHOTO RELEASE

I, _________________________________,   the parent of ______________________________________

(Please circle one)  GIVE   /   DO NOT GIVE The Medway Dance Authority permission to use my child’s photos
from studio events, recital photos, etc.  for use on The Medway Dance Authority Website, Advertisements &
Brochures.   Signed________________________________________  Date _______________________

How did you hear about the The Medway Dance Authority (Please circle):

Website         Newspaper       Business Card Display          Referred By: _________________


REGISTRATION FEES

$25.00 Single Student Registration Fee   OR   $45.00 Family Registration Fee

All currently enrolled students may register as of April 1st – NO SOONER!!! Forms turned in early will be
returned.  


Registration forms may be mailed to: The Medway Dance Authority   P.O. Box 150   Medway, MA 02053

Priority enrollment for current students will be April 2nd   – April 14th.  Registration will be first come, first
serve during this time for current students.  If you need a particular day and time you should try to register
early.  You may enroll by filling out this registration form and enclosing it in an envelope with your registration
fee (see fees above).  Please make sure you fill in the correct day, time, and cost of classes.  Please call first
if your child wishes to try a new style of dance. His/ Her class may not be the level indicated above and he/she
may need to wait for a slot to open.  If you do not hear from us your child will automatically be enrolled in the
programs you have requested on the back of this form.  If a class is full we will contact you immediately!  
Please call 533-9171 with any questions you may have!



REGISTRATION FORM & CONTRACT

Please register my child, _________________________________ for the 2019- 2020 dance season. I have
enclosed my non-refundable registration fee of $25.00 for a single student or $40.00 for a family registration
to register for the classes below.  I will contact The Medway Dance Authority by September 1, 2019 if we will
not be able to attend the 2019/202
0season. I understand that tuition, if not paid in full by September 1, 2019
will always due by the 1st day of each month (September 1st  – May 1st ) and that I will be charged a $10.00
late fee after the 1st day of the month. I understand that I will NOT receive the 5% multi-class discount if my
payment is late and will also be required to pay the $10.00 late fee.  I also agree to pay a $20.00 penalty for
any returned checks.

I understand that the costume payment of $65.00 per class is due by October 15, 2019. This payment must
be made separate from tuition and is non-refundable. However, if the costume payment has been made, but
the child is unable to continue in the dance program, he/she will still receive his/her costume.

I understand my payment options. I understand that payment may be made in full for the year by September
1st or I may choose to make 9 equal payments September 1st – May 1st. I understand that tuition is based on
the dance season, not based on how many classes per month.

I understand that my child must follow all studio rules and safety regulations. My child will also be at class on
time so that he/she will not miss critical warm up exercises. I understand and my child understands that by
missing class time and by not following rules, he/she runs the risk of injuring himself/herself.  I also
understand that with any physical activity, including dance, there is always a risk of injury and I will not hold
The Medway Dance Authority, it’s staff  and it’s representatives responsible for any injuries or loss of
valuables that may occur during the program.

I, ____________________________________________________ and my
child____________________________________________ will follow all of the rules & regulations of The Medway Dance
Authority as outlined in the handbook. 2019/202
0 handbooks must be picked up by a parent or guardian at the first dance class
in September.

Please register my child,  ___________________________________________ for the following classes.

CLASS                                                           DAY                                              TIME                                              COST


_________________________________________________________________________________


_________________________________________________________________________________


_________________________________________________________________________________


_________________________________________________________________________________


_________________________________________________________________________________


_________________________________________________________________________________

YEARLY TUITION TOTAL                   MONTHLY INSTALLMENT  TOTAL (If you choose Option C)


_________________________________________________________________________________

Families enrolled for more than 1 class may take a 10% discount monthly if payments are made by the 1st
day of each month!!!

1ST payment of Option 3 monthly installment payment plan due by September 1, 2019

Receive a 5% discount if full year is paid by June 1, 2019
(May be combined with 5% multi –class discount if you are eligible)

REGISTRATION  FEE  DUE  NOW!!!
$25.00 single student/$45.00 Famil
y

_____OPTION  A  I choose to Pre-pay the 2019/2020 Season in full by June 1, 2019 to receive the extra 5%
Discount (5% Multi-class discount may also be added if applicable for a savings of 10%) Payment may be
dropped off at the dance studio or mailed to: The Medway Dance Authority P.O. Box 150 Medway,  Ma.  02053


______OPTION B  I choose to pay for the 2019/2020 season in full by September 1, 2019 (5% Multi-class
discount may be taken if applicable )


______ OPTION C   I choose to break my 2019/2020 payment into 9 payments, due September 1, 2019
through May 1, 202
0 (5% Multi-class discount may be taken if payments are made on-time (by the 1st DAY of
each month, not the 1st class) The multi-class discount may not be taken if payment arrives after the 1st day
of the month. A $10.00 late fee will also be due if payments are late.)



OFFICE USE ONLY

REGISTRATION FEE PAID BY:    CASH    OR   CHECK #__________   ON        /      /

If paying in full, please indicate amount and date paid:  $______________  on      /     /