MAIN STREET DANCE REGISTRATION

Sept.1,2010

Dancer's First Name (please print)

Class Name

Instructor

Fort Atkinson Parks & Recreation's
MAIN STREET DANCE STUDIO

                                               Mailing Address: 30 N. Water St. W., Fort Atkinson, WI 53538              Phone: (920) 563-7781

     __________ Returning Student (Fall/Spring 2009/2010)                 __________ New Student (including Summer 2010 program)

Dancer's Last Name: (please print)

Address:                                                                                                       How Many Years in Program?:

City:                                                                                                                                                        Zip:

Home Phone #                                                                                                         2nd Phone #

Parent's Names: (please print)

email: (Dept. use only)

		Installments:
(A) Half of Subtotal				Subtotal	(A)
	Costume Fee Due Day of Registration		Costume Deposit - $25 per class
	(C) Total		Total		(B)
	If two payments = 1/2 of Subtotal (A) - plus costume deposit				(C)
	Office Use Only	Payment two (2) Due by January 14, 2011			(D)
LINE (F)	Amount Paid:
	Check #/Cash:		Apparel/Shoes/Other
	Date:
	By:

LINE (D)	Balance Due: (Due 1/14/11)
	Amount Paid:
	Date Paid: Check/Cash:
	By:		Apparel Sub-Total		(E)
	Amount Due:		Line B or C + Line E = total paid 9/11/2010		(F)

Make Checks Payable to "City of Fort"