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Pacific Interior Pilates Inc.

Registration Form - 09/10

Email: _____________________________                               Date: _____________________________

DANCER’S NAME____________________________________________________________________

PARENT (S) _________________________________________________________________________

HOME PHONE_________________________________WORK_________________________________

MAILING ADDRESS___________________________________________________________________

_______________________________________________POSTAL CODE________________________

BIRTH DATE (M/D/Y)________________________AGE AT REGISTRATION_____________________

I understand that I require to follow school policies.  I will show the school consideration of their commitment to my child by giving
30 days written notice prior to discontinuing classes.  Fees will not be reimbursed without written notice or Dr.’s certificate.

 

Parent’s Signature _________________________________________________

10 MONTHS POST-DATED CHEQUES REQUIRED

FIRST OF EACH MONTH

REGISTRATION FEE $15.00/ FAMILY $20.00

CHEQUES PAYABLE TO: Pacific Interior Pilates Inc.
OR sign Visa/Mastercard Autoriziation form

HIGHLAND CATEGORY     

PREMIER 1  ______                          PREMIER 2 ______                          PREMIER 3 ______

DANCERS PILATES                       LEVEL 1 ______                      LEVEL 2 ______

   *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *

** For Office Use Only

Registration Fee Pd. (non- refundable)___________________Post-dated cheques to________________

Total Rate per Month______________________ Family Rate per Month__________________________

Adjustments - Month & Rates ____________________________________________________________

Notes: ______________________________________________________________________________