Please complete an individual form for each student and return with payment to Hopkins Dance Center.

Student's name:	_______________________________		Birthdate:	_____/_____/_____
Parent's name:	_______________________________		Home phone:	(___)____________
Address:	_______________________________		Work phone:	(___)____________
City:	_______________________________		Zip code:	_________________
Please consider me for placement on Competition Teams    (see office for paperwork):   _______

Class code #:   Amount $:   Class code #:   Amount $:   Class code #:   Amount $:   Class code #:   Amount $:   Class code #:   Amount $:   Class code #:   Amount $:

Class code #:   Amount $:   Class code #:   Amount $:   Class code #:   Amount $:   Class code #:   Amount $:   Class code #:   Amount $:   Class code #:   Amount $:

Gypsy cards:     6 classes @ $85 ______     9 classes @ $125 ______     12 classes @ $165 ______
Total fees paid: ___________
Please make checks payable to: Hopkins Dance Center	Fees are non-refundable!
Not responsible for injuries sustained in class. I agree to comply with the rules & regulations of Hopkins Dance Center.
Parent signature: _______________________________________	Date: _______________