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Dancer’s Name (s) ______________________________________________________ Date of Birth _____________
Class Name _________________________________ Day ___________ Time __________________ Class Name _________________________________ Day ___________ Time __________________ Class Name _________________________________ Day ___________ Time __________________ Guardian or Responsible Party ____________________________________________ Home Phone #_________________________ Mobile # ________________________ Mailing Address ___________________________________________________________________________ Emergency Contact Information – Should be someone available during the time of your child’s class. Name _________________________________________ Phone ___________________________________ E-Mail Address ____________________________________________________________________________ This is very important. You will only receive a few messages a semester, so please make sure email from KDA is not being blocked or going into your spam folder. If you do not have email, please check in often to make sure you are receiving all of the latest information. Thank you!
This waiver is valid for the duration of dancer’s participation and enrollment at Konocti Dance Academy. I am legally authorized to take responsibility for this dancer and enroll him/her in this activity. Due to the limited space available, I understand that tuition is non-refundable. Liability Waiver I understand that there are risks associated with, arising out of, and inherent to the activity of dance. In recognition of this, I agree to release Annette Lee and the Konocti Dance Academy, and hold them harmless of all liability. I take full responsibility for the above mentioned minor(s) and hereby acknowledge that I am knowingly and voluntarily assuming full responsibility for all risks of injury to the minor(s) arising out of active participation of any Konocti Dance Academy class or activity. I understand that when my child is not inside the dance classroom, he or she is unsupervised. It is my (parent or guardian) responsibility to ensure and provide for the appropriate supervision, whereabouts, comings and goings, and general safety of my child. Photo Waiver I authorize pictures and/or videos of the above mentioned dancer(s) to be taken during rehearsals and/or performances. I understand that these pictures are the property of Konocti Dance Academy and may be used for commercial, advertising or promotional purposes.
Guardian or Responsible Party Signature __________________________________________ Date _________________________ |
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Konocti Dance Academy 2010 Registration Form Print this page using your browser’s print function. All credit card info is destroyed once payment is processed. Mail form and payment to P.O. Box 1777 Clearlake, CA 95422. Early registration is encouraged, as enrollment is on a first come, first served basis. If your desired class is full, we will contact you. Otherwise, if your payment is processed, you may assume that you have been successfully registered and we will see you in class! |
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Complete to Pay Via Mail-In Credit Card (Visa MC Discover)
Name on Card_______________________________________
Card # _____________________________________________
Expiration Date ______________________________________
Billing Address (Numbers Only) _________________________
Billing Address Zip Code _______________________________
3-digit security code on back of card _____________________
Please Circle: Plan A (Charge me for everything in full - any applicable discounts applied.) or Plan B (Charge me in full for the apparel, costume, or uniform and half of the total tuition amount - any applicable discounts applied.) Please check one of the following: _______ I will come in to KDA in person to pay the second half of my tuition payment when it is due. _______ Please automatically bill my credit card when my second payment is due.
Signature __________________________________________
Date ___________________ |
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Semester Tuition and Payment Plans Spring Costume Recital Fee Mommy & Me, PC Rehearsal: $128 TwinkleStars $40 TwinkleStars. Hippity Hop (30 min): $148 Hippity Hop $35 Starlets, KinderStars, Bhangra Jrs. (45 min): $178 KS, Stlts, BJrs $45 SuperStars, Hip Hop, and All Others - (50 min): $188 SuperStars $45 Juniors III (90 minutes): $248 Hip Hop $35 Bhangra, PC $60 Tuition is due at the beginning of the semester. Late enrollees’ tuition will be pro-rated according to start date. Two tuition payment plans are available (tuition only - if applicable, costumes and uniform/apparel must be paid in full upon registration): Plan A: Costume, uniforms, or apparel and tuition payment in full upon registration. Upon request, a $10 discount will be offered to Plan A customers who pay their balance in full with cash or a money order. Plan B: Costume, uniforms, or apparel paid in full, half of tuition paid upon registration with the remainder due 30 days after registration (Plan B is only offered during the first 4 weeks of the semester). Sibling / Multi-Class Tuition Discount: For families with siblings or students taking multiple classes, tuition for first class is full price, tuition for additional classes of equal or lesser value is 20% off full price. Does not apply to costumes, uniforms, or apparel.
Please calculate your tuition payment with any applicable discounts.
Total Amount Enclosed $ ___________________________
Please note that tuition refunds cannot be granted for students who are unable to complete the semester. |