Performance Plus Dance
610 North Greece Road, Hilton, NY 14468
585-392-5355
** 2012 Summer 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 2012 Classes : (Competition Students may write " All applicable classes" :
Student # 2 :
Student Name
Date of Birth
Desired 2012 Classes : (Competition Students may write " All applicable classes"
Student # 3 :
Student Name
Date of Birth
Desired 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 $25.00 per student
Please submit registration form with Registration Fee
PLEASE BE SURE TO PRESS "SUBMIT" BUTTON AT THE BOTTOM OF THE PAGE
Credit Card #
Check #
Cash
Date Paid _
Summer Camp is July 23rd-August 16th, 2012
Registration fee due with registration form
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 #
Exp Date:
City, State, Zip
Tank Top Size: (please put and X in the box)
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Tank Top Size: (please put and X in the box)
Tank Top Size: (please put and X in the box)
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