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Payment and Form can also be mailed to: 6317 Courthouse Rd, Prince George, VA 23875

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Payment and Form can also be mailed to: 6317 Courthouse Rd, Prince George, VA 23875

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  1. 2009 Summer Registration FormStudent Name _____________________________________________________________________Age __________ Home Phone#_____________________ Cell # _____________________Email______________________________Parent/Guardian_________________________________________________________________________________ Address__________________________________________________________________________________________# Where You Can Be Reached During Dance Classes/Camp Hours__________________________________Turn Form and Payment in by April 25th and Registration Fee will be WAIVED for the Summer AND 2009/10 Dance Season.Registration Fee…..WAIVED if payment’s received by 4/25/09. Registration Fee…..$20.00(If paid after 4/25/09)…..This payment will waive the annual Registration Fee for 2009/10.Dance Card4 classes: $456 classes: $658 classes: $80UNLIMITED classes: $100Parent/Child: $22.50Tumbling Camp: $45.00Total Amount Enclosed _________ Check Number_________Card#______________________________________________________ Expiration Date______________________ We accept Visa, MasterCard and personal checks. There is a $25.00 fee on all returned checks. Waiver of ResponsibilityI am aware that all forms of dance and the acrobatic exercises associated with it, place unusual stresses on the body and carry with them the risk of physical injury. I assume this risk and agree that Gotta DANCE! School of Performing Arts, Inc., its staff, and the facilities of this dance school shall not be liable in any way for injuries sustained during attendance of the programs or any of its functions. If I do not wish to have my child’s picture printed in the newspaper or any other publication, I will put this in writing and submit to the Owner, Tara R. Peyton-Burgess.__________________________Student’s Name __________________________Parent/Guardian’s Signature/Date Payment and Form can also be mailed to: 6317 Courthouse Rd, Prince George, VA 23875 861-DNCE (3623) www.gottadance23875.com Tara R. Peyton-Burgess, Owner, Artistic Director

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