Performance Plus Dance
610 North Greece Road, Hilton, NY 14468
585-392-5355
** 2011-2012 Fall Registration Form **
Student Name
Date of Birth
Address
Home Phone
Child's Cell Phone (if available)
Parent's Name & Cell Phone
Parent's E-mail Address ( Please submit for billing - MUST HAVE ON FILE)
Desired 2011-2012 Classes : (Competition Students may write " All applicable classes" :
Family Member # 2 :
Student Name
Date of Birth
Desired 2011-2012 Classes : (Competition Students may write " All applicable classes" :
Family Member # 3 :
Student Name
Date of Birth
Desired 2011-2012 Classes : (Competition Students may write " All applicable classes" :
Payment in form of Cash, Check or Charge (Visa, Mastercard, or Discover accepted)
Fall Registration fee ($30.00 per student or $40.00 per family)
Please submit registration form with Registration Fee & Recital Fee
PLEASE BE SURE TO PRESS "SUBMIT" BUTTON AT THE BOTTOM OF THE PAGE
Credit Card #
Check #
Cash
Date Paid _
Recital fee ($60.00 per student or $70.00 per family)
Date Paid _
Cash
Check #
Credit Card #
All schedules will be mailed August 29-September 2, 2011
Artistic Director/Owner - Patty Bellucco
Office Staff - Cheryl Johnson & Lisa Nuccitelli
All forms are available through our website - www.performanceplusdance.com
PLEASE PRESS "SUBMIT" BUTTON
SC #
SC #
Exp Date:
Exp Date:
City, State, Zip
