2022/2023 Registration Form Memorial Dance Center 9392 Gaylord Dr. Houston, TX 77024 info@memorialdance.com 713-468-5700

Step 1 of 4 - Student Info

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Student Name(Required)
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Registration Complete

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Student Name(Required)
Address(Required)
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Class Options

  • Creative Movement (2 1⁄2 Year olds)
  • Tap/Ballet Combo (ages 3-5)
  • Tap/Ballet/Jazz Combo (Kindergarten)
  • 1st & 2nd grade (Tap, Ballet, Jazz and/or Hip-Hop)
  • 3rd grade & older (Tap, Ballet, Jazz, Hip-Hop, and/or Contemporary)
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Classes
List Requested Class(es) Below
Dance Subject
Day
Time
 

Enrollment Agreement

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I, the undersigned parent or legal guardian of the above listed student, understand that my signature on this document constitutes acceptance of the following conditions of my child’s enrollment at Memorial Dance Center.

DISCOUNT POLICY

The listed student’s regular monthly tuition rate is $________ per month. If I pay the tuition in full BEFORE, not on, the first day of the month for which tuition is due AND my account shows a zero balance, I am entitled to the discounted rate of $________. Furthermore, I understand that if my account shows a balance due on the first day of any month, I am NOT entitled to a discount for that month for any reason. If my credit card is denied for any reason, I have 10 days to pay balance in order to still receive the discounted rate.

TERMINATION OF ENROLLMENT

I understand that if I wish to terminate the above listed student’s enrollment at Memorial Dance Center, I must sign a “Termination of Enrollment” form and return it to the Memorial Dance Center office by the 25th of the month. I acknowledge that tuition is based on enrollment and not on attendance. My tuition liability ceases effective the first day of the month following receipt of the signed “Termination of Enrollment” form by the Memorial Dance Center office. In addition, my child’s enrollment can be terminated by Memorial Dance Center if my child misses 4 consecutive classes without prior notice to the office or if tuition is over 15 days late. I will be responsible for any and all tuition up to the date my child’s enrollment is terminated.

AUTHORIZATION OF EMERGENCY MEDICAL CARE

I hereby authorize the staff and director, representing Memorial Dance Center, to give consent for any and all necessary emergency medical care for my child, ____________________________, while said child is in the custody of Memorial Dance Center personnel. I also hold Memorial Dance Center or any other Memorial Dance Center personnel harmless in such an event. Pertinent medical conditions of my child are:

PHOTO RELEASE

I give Memorial Dance Center the absolute right and permission to use my child’s photograph(s) in its promotional materials and publicity efforts. I understand that the photograph(s) may be used in a publication, print ad, direct- mail piece, electronic media (e.g. video, CD-ROM, Internet, World Wide Web), or other form of promotion. I release Memorial Dance Center, the photographer, their offices, employees, agents, and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. Additionally, I will make no monetary or other claim against Memorial Dance Center for the use of the photograph(s)/video.

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Photo Release
Enrollment Agreement
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Credit Card Authorization Form

Cardholder Information

Name
Billing Address

Credit Card Information

Credit Card
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Authorization

2022/2023 Registration Form
Memorial Dance Center 9392 Gaylord Dr. Houston, TX 77024 info@memorialdance.com
713-468-5700
First Name: [field id="field_00c079a"]
Middle Initial: [field id="field_a119633"]
Address: [field id="field_d7303e0"]
ZIP: [field id="field_9741f5b"]
Home Phone: [field id="field_a119633"]
Age: [field id="field_130a5ce"]
Birthdate: [field id="field_0f26752"]
Grade (As of Aug.): [field id="field_b655b37"]
School: [field id="field_aa0497e"]
Mother's Name: [field id="field_be74261"]
Cell: [field id="field_49313f6"]
Work: [field id="field_d948c19"]
Father's Name: [field id="field_f7a083e"]
Cell: [field id="field_a52cd14"]
Work: [field id="field_14ee4ea"]
Email: [field id="email"]
Student’s email: [field id="field_519e646"]
How did you hear about us?
[field id="field_519e646"]
Registration Fee: $____________ Monthly Tuition: $_____________ Registration fees & August tuition are non- refundable. Class options are listed below. Specific days and times are listed on our website.
  • Creative Movement (2 1⁄2 Year olds)
  • Ballet/Tap Combo (ages 3-5)
  • Ballet/Tap/Jazz Combo (Kindergarten)
  • 1st, 2nd & 3rd grade (Ballet, Tap, Jazz and/or Hip-Hop)
  • 4th grade & older (Ballet, Tap, Jazz, Hip-Hop, and/or Contemporary)
List Requested Class(es) Below.
Dance Subject
Day
Time
For office use only:
Cash $__________ Receipt #__________ Check $__________ Check #__________ Check Name: _____________________ Credit Card Type: ______________ Amount $____________ Receipt #___________________ Initial: ___________________
2022/2023 Registration Form
Memorial Dance Center 9392 Gaylord Dr. Houston, TX 77024 info@memorialdance.com
713-468-5700
Last Name: [field id="name"]
First Name: [field id="field_00c079a"]
Middle Initial: [field id="field_a119633"]
Address: [field id="field_d7303e0"]
ZIP: [field id="field_9741f5b"]
Home Phone: [field id="field_a119633"]
Age: [field id="field_130a5ce"]
Birthdate: [field id="field_0f26752"]
Grade (As of Aug.): [field id="field_b655b37"]
School: [field id="field_aa0497e"]
Mother's Name: [field id="field_be74261"]
Cell: [field id="field_49313f6"]
Work: [field id="field_d948c19"]
Father's Name: [field id="field_f7a083e"]
Cell: [field id="field_a52cd14"]
Work: [field id="field_14ee4ea"]
Email: [field id="email"]
Student’s email: [field id="field_519e646"]
How did you hear about us?
[field id="field_519e646"]
Registration Fee: $____________ Monthly Tuition: $_____________ Registration fees & August tuition are non- refundable. Class options are listed below. Specific days and times are listed on our website.
  • Creative Movement (2 1⁄2 Year olds)
  • Ballet/Tap Combo (ages 3-5)
  • Ballet/Tap/Jazz Combo (Kindergarten)
  • 1st, 2nd & 3rd grade (Ballet, Tap, Jazz and/or Hip-Hop)
  • 4th grade & older (Ballet, Tap, Jazz, Hip-Hop, and/or Contemporary)
List Requested Class(es) Below.
Dance Subject
Day
Time
For office use only:
Cash $__________ Receipt #__________ Check $__________ Check #__________ Check Name: _____________________ Credit Card Type: ______________ Amount $____________ Receipt #___________________ Initial: ___________________
Memorial Dance Center Credit Card Authorization Form
Student Name: [field id="name"]
Family Number: [field id="name"]
CARDHOLDER INFORMATION
Name: [field id="name"]
Billing Street Address: [field id="name"]
City: [field id="name"]
State: [field id="name"]
Zip Code: [field id="name"]
Phone: [field id="field_a119633"]
Email: [field id="field_a119633"]
Applies to any and all dance related charges to your account for the 2022/2023 dance year.
CREDIT CARD INFORMATION
Credit Card Type: [field id="name"]
Type: [field id="name"]
Credit Card Number: [field id="name"]
Expiration Date: [field id="field_a119633"]
Security Code: [field id="field_a119633"]
I, the above-named authorized cardholder, give Memorial Dance Center and its representatives express authorization to charge my credit card for the Authorized Charges indicated above. I understand that this form constitutes a legally binding contract and that by affixing my signature to this form, I will be held responsible for all Authorized Charges as well as any and all collection and legal fees. By signing this Credit Card Authorization form, I acknowledge receipt and understanding of its contents.
Cardholder Signature X [field id="field_a119633"]
Date: [field id="field_a119633"]
Enrollment Agreement
Student Name: [field id="name"]
Name of Parent/Legal Guardian: [field id="name"]
I, the undersigned parent or legal guardian of the above listed student, understand that my signature on this document constitutes acceptance of the following conditions of my child’s enrollment at Memorial Dance Center.
DISCOUNT POLICY
The listed student’s regular monthly tuition rate is $________ per month. If I pay the tuition in full BEFORE, not on, the first day of the month for which tuition is due AND my account shows a zero balance, I am entitled to the discounted rate of $________. Furthermore, I understand that if my account shows a balance due on the first day of any month, I am NOT entitled to a discount for that month for any reason. If my credit card is denied for any reason, I have 10 days to pay balance in order to still receive the discounted rate.
TERMINATION OF ENROLLMENT
I understand that if I wish to terminate the above listed student’s enrollment at Memorial Dance Center, I must sign a “Termination of Enrollment” form and return it to the Memorial Dance Center office by the 25th of the month. I acknowledge that tuition is based on enrollment and not on attendance. My tuition liability ceases effective the first day of the month following receipt of the signed “Termination of Enrollment” form by the Memorial Dance Center office. In addition, my child’s enrollment can be terminated by Memorial Dance Center if my child misses 4 consecutive classes without prior notice to the office or if tuition is over 15 days late. I will be responsible for any and all tuition up to the date my child’s enrollment is terminated.
PHOTO RELEASE
I, (parent’s name, please print) ___________________________________, give Memorial Dance Center the absolute right and permission to use my [___] son’s [___]daughter’s photograph(s) in its promotional materials and publicity efforts. I understand that the photograph(s) may be used in a publication, print ad, direct- mail piece, electronic media (e.g. video, CD-ROM, Internet, World Wide Web), or other form of promotion. I release Memorial Dance Center, the photographer, their offices, employees, agents, and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. Additionally, I will make no monetary or other claim against Memorial Dance Center for the use of the photograph(s)/video.
AUTHORIZATION OF EMERGENCY MEDICAL CARE
I hereby authorize the staff and director, representing Memorial Dance Center, to give consent for any and all necessary emergency medical care for my child, ____________________________, while said child is in the custody of Memorial Dance Center personnel. I also hold Memorial Dance Center or any other Memorial Dance Center personnel harmless in such an event. Pertinent medical conditions of my child are:
Signature of Parent or Legal Guardian
Date