Registration Form
Maricopa Dance Academy Suite 101
21596 N. John Wayne Pkwy
Maricopa, Arizona 85239
520-494-2937
Billing Name ______________________________
Address _________________________________ State _______ Zip ______
Home Phone ____________________
Email _________________________
Parent 1 ______________________ Cell Phone _______________
Employer _____________________ Work Phone ______________
Parent 2 _____________________ Cell Phone ________________
Employer ____________________ Work Phone _______________
Emergency Contacts ____________________________
____________________________
Student Name __________________
Address _______________________
City ______________ State _________ Zip _______
Birthdate ___________ Sex _____ School ________________ Grade _____
Medical Info __________________________________________________
Dr. Name _____________________
Classes ______________________Level ___ Room__ Day____Time ____ Tuition___
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Registration Fee ______ Total Tuition ______
Parent Signature: _________________________ Date: ___________
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