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ENROLLMENT FORM: WESTFIELD STUDIO
Student's Name:_______________________________________________________
Age as of Sept. 1:_____ Date of Birth:______________________________________
Street Address:________________________________________________________
City, State & Zip:_______________________________________________________
Telephone No:(______)__________________E-Mail:____________________________
Class Day & Time:_______________________________Instructor:_________________
Class Day & Time:_______________________________Instructor:_________________
Class Day & Time:_______________________________Instructor:_________________
Class Day & Time:_______________________________Instructor:_________________
Class Day & Time:_______________________________Instructor:_________________
Parent's Name:________________________________________________________
I understand that dance and gymnastics involves twisting and turning, and injuries may result. All families are responsible for their own medical coverage and insurance. I also give permission for any dance pictures to be used in local newspaper articles, studio advertising or on our web-site.
Signature___________________________________Date:______________________
	1 class per week- $34 per month 2 classes per week- $60 per month 3 classes per week- $83 per month 4 classes per week- $104 per month
		Each Westfield student must pay a $10 nonrefundable registration fee.
Please enclose this completed form along with a nonrefundable check for September lessons plus the Ten dollar ($10.00) registration fee and return to...
New England Dance and Gymnastics Centers 28 Southwick Road  Westfield, MA 01085
Amount enclosed- $____________