Registration Form

Name:

Address:

City:

State:

Zip:

Occupation (for adults):

Home Phone:

Work Phone:

Email Address:

Classes (day & time):

For Kids (age):

Grade:

Date of Birth:

Parent Names:

	Amount Paid:	Date Paid:
Fall Payment:
Winter Payment:
Spring Payment:
Summer Payment:

How did you hear about us?

Liability Disclaimer:
The studio and the instructors are not liable for personal injuries or loss or damage to personal property. Since this is a physical activity, injuries may occur. Each student may decline to participate in any activity which may be harmful and is also responsible to inform the instructor of any physical limitation which may prevent full participation in class.

Signature: ___________________________________________________________________
A parent signature is required for children under 18.

Please print this form, fill it out, and mail with payment to:

Casco Bay Movers Dance Studio
517 Forest Avenue
Portland, Maine 04103

Please make checks payable to Casco Bay Movers
Call with questions: 871-1013