Dominy School of the Performing Arts, Inc.

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

Summer Classes Wanted
Relation
Business Phone
Cell Phone
Name of person completing form

PLEASE NOTE: REGISTRATION FEE OF $10.00 MUST BE SUBMITTED WITHIN FIVE (5) BUSINESS DAYS OF SUBMITTING THIS FORM

To finalize your registration, please submit your $10 registration fee to the following address within five (5) business days:

Dominy School of the Performing Arts, Inc.

2204 Salem Road

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.

Hours/Week	Total Cost For Any 4 Weeks	Total Cost For Any 5 Weeks
1/2 Hour/ Age 3	$29.00	$36.00
1 Hour/ Week	$51.00	$63.00
1 1/2 Hours/ Week	$75.00	$94.00
2 Hours/ Week	$90.00	$113.00
2 1/2 Hours/ Week	$109.00	$136.00
3 Hours/ Week	$128.00	$167.00

	Dominy Summer Camps We've had a great summer! See you next year!