MNR Dance Factory

MNR Dance Factory
Online Secure Registration

Please enter all the information requested. Use the tab key to go to the next field.
Please be sure not to use the Enter key until you are completely done with this form. Updated as of 9/3/07

Today's Date:

Student First Name
Student Last Name
Student Date of Birth
Sex	Female Male

Please provide the following Parent/Guardian information:

First Name
Last Name
Street Address
Address (cont.)
City
State
Zip
Home Phone
FAX
Work Phone
E-mail
Cell Phone

Go to section which you are interested in: Summer Camp vs Fall and Spring Class

Summer Camp:

Choose Camp Week (To choose more than one week hold down ctrl and click on choices)
Number of weeks
Enter Special Notes
$100 non-refundable Deposit Required

Fall & Spring Classes:

Please provide the following choices for your First Class:
(Use down arrow to make your choice)

Class Name
Class Number	Number under Time on Schedule
Day of Week
Age Level
Time	Please enter time from Schedule
Level

Please provide the following choices for your Second Class:

Class Name
Class Number	Number under Time on Schedule
Day of Week
Age Level
Time	Please enter time from Schedule
Level

Please provide the following choices for your Third Class:

Class Name
Class Number	Number under Time on Schedule
Day of Week
Age Level
Time	Please enter time from Schedule
Level

Please provide the following choices for your Fourth Class:

Class Name
Class Number	Number under Time on Schedule
Day of Week
Age Level
Time	Please enter time from Schedule
Level

Please provide the following choices for your Fifth Class:

Class Name
Class Number	Number under Time on Schedule
Day of Week
Age Level
Time	Please enter time from Schedule
Level

Please provide the following choices for your Sixth Class:

Class Name
Class Number	Number under Time on Schedule
Day of Week
Age Level
Time	Please enter time from Schedule
Level

Annual Registration Fee: $35.00

	BILLING
Payment Option:	Note: Payments are due prior to the first day of each session. If paying by check, check must be received prior to first class.
Credit Card Type:
Charge Auth:	Check here if you authorize MnR to charge your credit card during the first week of each semester (Sept & Feb) if payment has not been received in another form.
Card Number:	Credit Card Must be on File
Expiration Date:
Amount:	You authorize MnR to Charge This Amount to the above credit card.
Release:	I am aware that my child named above will be exposed to certain risks that exist in athletic activity, including safety and personal injury risk. I am voluntarily allowing my child to participate in these activities. I agree that I will not sue on behalf of my minor child, or otherwise make any claim against MnR Dance Factory, Inc. or any of its affiliates, employees, agents or members for any injury or damage, however caused, by the MNR Dance Factory, as a result of my minor childs’ participation in a dance class or program. I have read the above and by checking this box agree.