Registration

Event:

Start Date/Time:

End Date/Time:

Fee per Student:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Home Phone:	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Emergency Contact Info

Students entered below will be added to your family's account

Questions/Options:


Please list which private lesson package you would like to purchase 1) One 1 hour lessons- $75 2) One 30 minute lessons- $45 3) Five 1 hour lessons- $340 4) Five 30 minute lessons- $195*
I understand that my card on file will be charged the day I register for private lessons which I have selected and authorized CDA to charge.*
Please list an emergency contact name and number (other than that of the parent listed on the registration form) in case of an emergency.*
I understand that if I do not give 24 hour cancelation notice to the instructor and do not attend my lesson I will be charged and not refunded the money as the teacher has blocked that time and studio*
If you have a preference of instructor, please provide their name below. If you don't have a preference please put N/A. *

Additional Information:

Liability Release

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I've read the above and agree.

Assumption of Risk

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Photos

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Signature

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I've read the above and agree.

Enter your Full Name: