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You may print, fill out and send to
us with your fee.
Please Note: Registration Confirmation is your deposited check and you will receive an email in the beginning of September before before classes start or after your registration if registering later.
Registration Form:
Name:______________________________
Age (by Sept. 1st) (DOB):__________________________
Address:__________________________
__________________________________
__________________________________
Email(s) (for our monthly newsletter)
__________________________
Phone(s):______________________________
Emergency #:_______________________
Name & Relationship to Student______________
Please list any Special Needs, Allergies, Disabilities, Medications etc we should know about:________________
Classes / Times you are Registering for:
1._______________________/__________
2._______________________/__________
3._______________________/__________
(you may continue to add)
Dance experience, if any: (also list years at Reflections for Loyalty
Discount)
__________________________________
__________________________________
Both Parents Names & Signature:
(MUST Print, Sign, & Date)
(signifies understanding of and adherence and agreement to all policies,
Emergency Medical treatment if needed and release of all liability
from “Reflections School of Dance Inc ” and it’s teachers)
____________________________________
Please include Non-Refundable $20 Registration Fee with form.
(+ $5 for each additional family member)
If you’re a new student also list below a name if anyone referred
you.
Send to:
LEN & DEBBIE WIENS
Directors
13823 Seattle Hill Rd.
Snohomish, WA 98296
425-338-9056 (Ph.& Fax)
dance@reflectionsschoolofdance.com
www.reflectionsschoolofdance.com
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