Pom Pom Registration form

Pom Pom Registration Form

Registration is not complete until you have submitted full payment for the class.

You may mail payment to 320A Central Avenue - Butner, NC 27509 or drop payment in the lock box outside the studio.

* Indicates required field

Student Name *

First

Last

Student Age *

Student Birthday *

Parent Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Please list any medical concerns I should know about this student. *

Pom Pom classes are from 6pm - 7pm on Tuesdays and Thursdays on May 19th - May 28th. (4 classes in total) *

I understand that Pom Pom classes are held on the dates listed above and the price per student is $50 payable in advance.

Media Release Statement. I hereby consent that photographs and videos taken of my child during class may be used by Melissa and / or Melissa's School of Dance for use on our web sites and / or for promotional material. Names of students will not be published. *

Yes No

Melissa's School of Dance does not carry medical insurance for its students. It is required that all students be covered by their own family insurance policies and if any injury occurs it is understood that the student's own policy is your only source of reimbursement. *

By checking here, I have read and agree to follow all policies that are listed on this website and that are posted in the studio.

Submit