Dominy School of the Performing Arts, Inc.

FALL REGISTRATION FORM 2009-2010

Please fill out one (1) form for each student.

Name of Student*
Home Phone*
E-mail address*
*required fields
Age
DOB
Grade (if applicable)
Student’s address
City
State
Zip

Name of person completing form
Relation
Other family members registered:
Business Phone
Cell Phone
Occupation/Family Business (Optional)

I would like to register for the following classes:

Dance
Creative Movement (age 3)			Jazz (ages 9 & up)
			Jazz Funk/Hip Hop (9 & up)
Combination Classes			Ballet (ages 8 & up)
Tap/Ballet I (age 4-5)			Pointe
Tap/Ballet II (age 5-6)			Martial Arts
Tap/Ballet III (age 6-7)			Tribal Fusion Belly Dance
Tap/Ballet IV (age 7-8)			Other (Not Listed)

List previous training/experience/total years of dance

Number of years of Dance

Number of years completed at Dominy School

If new student, how did you hear about us?

Availability of classes is subject to having sufficient enrollment.
Our fall session begins on the first day of school in Rockdale, Co.

See Independant Contractors list for prices on

Karate, Drama, Ballroom, Belly Dance, Clogging, Competition Team, Irish, Vocals, and Music

PLEASE NOTE: Many classes take new students year round.

To finalize your registration, please submit your $25 registration fee (Fee will increase to $30.00 after August 15, 2008) to the following address within five (5) business days:

Dominy School of the Performing Arts, Inc.

2204 Salem Rd.

Conyers, GA

30013

If registration payment is not received within five (5) business days, then your registration placement will be forfeited and re-registration may be necessary. If you have any questions, please feel free to contact the studio at 770-388-7916.

Release: Clicking the submit button below constitutes a legal electronic signature, as specified by law. The submitter of this form states the following:

I have read the Handbook and Fee Schedule and as the parent, guardian, or participant of legal age myself, agree to assume full responsibility for carrying out the terms. I also agree to grant Dominy School of the Performing Arts, Inc. the right to publish or display the student’s photo or likeness for promotional purposes and give immediate minor first-aid in event of injury.