Student information:
Students name Birthday & Age:	* required
Email address:	* required
Parent Name & Telephone number: Mailing Address:	* required
My interest:
Register my child for the following class(es):	3-4 Tap & Ballet Combo 5-6 Tap & Ballet Combo Tap Ballet Jazz Hip-hop Boys Only Hip-hop Pom Lyrical (Teen) Pointe (ages 10 -17) Broadway Jazz Contemporary Pop Ballet (level 3/4) Acting Class Zumba
Day of Class: Time of Class:
Payment Method:
Credit Card Number: Exp. Date:
WAIVER: *SRDA requires a credit or debit card to be on file. Your monthly tuition will automatically be charged to your credit or debit card on the 29th of every month for the following month. WAIVER: By submiting this form, I give my child(ren) permission to participate in the South Riding Dance Academy (SRDA, INC.) program. I hold SRDA, Inc. harmless for any injury sustained to my child during any dance session or event planned, coordinated, & directed by SRDA, Inc. or any SRDA, Inc. volunteers, staff members, and employees.