CAPISTRANO ACADEMY OF DANCE
31734 Rancho Viejo Rd, Suites A & B
San Juan Capistrano, CA 92675
(949) 429-2662
31734 Rancho Viejo Rd, Suites A & B
San Juan Capistrano, CA 92675
(949) 429-2662
Registration Form
(Please Print, Fill-Out and Mail)
(Please Print, Fill-Out and Mail)
Billing Name: _________________________________________________________________________________________
Address: _____________________________________________________________________________________________
City: _______________________________________________ State: __________ Zip code: _______________________
Hm Phone: __________________________________ E-mail: _______________________________________________
Parent 1:_____________________________________________ Hm Phone: ____________________________________
Employer: ___________________________________________ Wk Phone: ____________________________________
Cell: __________________________________
Parent 2:_____________________________________________ Hm Phone: ___________________________________
Employer: ___________________________________________ Wk Phone: ____________________________________
Cell: __________________________________
Emergency Contact: ___________________________________ Phone: _______________________________________
Student Name: _______________________________________________________________________________________
First Last
Address: ____________________________________________________________________________________________
City: _________________________________________State: _____________ Zip code: _____________________________
Birth date: ______________________School: _____________________________________ Grade: ____________________
Doctor: _______________________________________________Phone: _________________________________________
Special Medical Condition/Needs: __________________________________________________________________________
Classes Course Description Studio Day Time Tuition
1. ____________________________________ _____ ___________ ___________ ______________
2. ____________________________________ _____ ___________ ___________ ______________
3. ____________________________________ _____ ___________ ___________ ______________
Registration Fee ___________ Total Tuition ______________
Parents Signature: Date:
I hereby hold harmless and release and discharge Capistrano Academy of Dance, its constituent organizations, including but not
limited to their officers, agents, employees and volunteers from any and all claims for personal injuries or property damage that my
child may suffer during classroom activities as a result of his/her participation in the activity described above.
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