Tupelo Academy of Dance Arts Online Registration

TUPELO ACADEMY OF DANCE ARTS......2224 WEST JACKSON ST......TUPELO, MS. 38801......662-844-4352

* denotes required fields

Referral Information

How did you hear about us?*

Family Information

Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info

Special requests?*

Other activity schedule*

Contact #1

Contact #1 First Name*

Last Name *

Mother/Grandmother*

How Can We Contact You?

Work # *

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Contact #2

Father First Name*

Last Name*

Type*

How can we contact you?

Home Phone

Work # *

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Student Email*

School*

Grade Level*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

What classes for each student*

Carpool group/names*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Student Email*

School*

Grade Level*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

What classes for each student*

Carpool group/names*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Student Email*

School*

Grade Level*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

What classes for each student*

Carpool group/names*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Student Email*

School*

Grade Level*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

What classes for each student*

Carpool group/names*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Student Email*

School*

Grade Level*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

What classes for each student*

Carpool group/names*

Add Another Student

Required Policies and Agreements

Release of Liability

As the legal parent or guardian, I release and hold harmless TADA, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of TADA, its owners and operators or in route to or from any of said premises.

I've read the above and agree.

Signature Text

I've read the above and agree.

Medical Emergency

The undersigned gives permission to TADA, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restictions, or condition and/or declare the paricipant to be in good physical and mental health.

I've read the above and agree.

Payment Information

Credit card e-payments will be processed on the first day of each month. Cash payments are due by the fifth day of each month. If accounts are paid after the tenth of the month, there will be a $15.00 late fee applied to the account balance. A penalty of $150 will be assessed if a student drops out of TADA after October 31st. Costumes will be ordered in December. All costume fees must be paid regardless of student participation.. 9 months of tuition is required regardless of unforeseen circumstances in order to protect business operations and teacher salaries. Online classes will be available for all under these circumstances. This includes student injury and extended absences from class participation.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip