Moonlite Dance Studio Contact Information Student Last Name Primary Contact Relationship to Student Address City Zip Email Phone Work Phone Secondary Contact Relationship to Student Address City Zip Email Phone Work Phone Student Information Student #1 Name Age Date of Birth Gender F M Cell Phone School Other Information (Allergies, Disabilities, Medication, ECT) Select Classes Ballet Jazz Lyrical Hip Hop Tumbling Combo Tap HipHop Modern *Summer Classes* Ballet w/South Tulsa Ballet Intensive Acro/Tumblint Tap Leaps and Turns Tumbling **Summer Camps** ERA Camp Barbie Camp Glow Camp Student #2 Name Age Date of Birth Gender F M Cell Phone School Other Information (Allergies, Disabilities, Medication, ECT) Select Classes Ballet Jazz Lyrical Hip Hop Tumbling Combo Tap HipHop Modern *Summer Classes* Ballet w/South Tulsa Ballet Intensive Acro/Tumblint Tap Leaps and Turns Tumbling **Summer Camps** ERA Camp Barbie Camp Glow Camp Student #3 Name Age Date of Birth Gender F M Cell Phone School Other Information (Allergies, Disabilities, Medication, ECT) Select Classes Ballet Jazz Lyrical Hip Hop Tumbling Combo Tap HipHop Modern *Summer Classes* Ballet w/South Tulsa Ballet Intensive Acro/Tumblint Tap Leaps and Turns Tumbling **Summer Camps** ERA Camp Barbie Camp Glow Camp Moonlite Dance, LLC. is hereby granter premission to take a photograph OR video of the student(s) to use for any advertising material inclouding the website, social media, print media, ext. Policies and Late Tuition: I have read and understand all articals presented in the policy form. I understand that tuition paid after the 10th of the month will incur a $15.00 late fee, as all feed not paid by the deadline. I also understand that an additional late fee will be applied to my account if there is an unpaied balance at the end of December. Costumes will only be handed out ans students will be allowed to perform once all tuition and fees are paid. I have read and agree to these terms. Care of Students, illnesses and injuries: Moonlite Dance, LLC. is instructors and assistancts are not responsible for providing before or after care for students. Parents with children under the age of 6 must stay with the child untill class begins and pick up the child instde the building when class is over.Students are not to be left at the school for excessive timer before or after class. Parents, Legal guardians of minor students or adult students hereby wave the right to and leagalaction from normal dance activity or any other activity conducted before, during, or after class time. I have read and agree with these terms. YES NO Administration of OCT Medicine:: My child has my permission to request OTC medication for injury or illness from Moonlite Dance Staff (Ages 12+ only)