MAIN STREET DANCE REGISTRATION

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 2010/2011)                 __________ New Student (including Summer 2011 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)

Age by
Sept.1,2011	Dancer's First Name (please print)	Class Name	Day	Time	Instructor	Fee
						$
						$
						$


Partial Payment			Full Payment
	Apparel	Apparel
	Total paid	Total Paid
	Check # or Cash	Check # or Cash
	Date Paid	Date Paid

	Office Use Only
	Amount Paid:
	Check #/Cash:	Apparel/Shoes/Other
	Date:
	By:

	Balance Due: (Due 1/14/12)
	Amount Paid:
	Date Paid: Check/Cash:
	By:	TOTAL:
	Amount Due:

Make Checks Payable to "City of Fort"