About Us

Fall 2010 Registration Form

Student's Name:  
Student's DOB:  
Age by 12/1/2009:  
Billing Address:  
City:       State     Zip:
Phone Number/Numbers:  
E-mail(please!!):  
(For Gym Bugs' use only - will not be distributed or sold under any circumstances!)

Please choose a class:

Pricing:
45 min: $280/semester ~ $56/month
1 Hour: $300/semester ~ $60/month
1.5 hours - 2 hrs 15 min: $420/semester ~ $84/month
2.5 - 3 hours: $600/semester ~ $120/month
3 hrs 15 min - 4 hours: $675/semester ~ $135/month

Registration Fee: $15.00 per year

Pay the full semester and receive a $20 discount!

Please choose a payment method:


If you are choosing the monthly payment option, you must fill out the following information:

Bank Name:  
Branch Location:  
City/State/Zip  
Routing #:   Account #:  

By signing below, I (we) agree that this authority is to remain in full force and effect until Revolution Dance and BANK have received written notification from me (or either of us) of its termination within a 30-day time period. A copy of this Authorization Agreement must be given to customers and will be provided by Gym Bugs, upon request, to the BANK.

Liability Policy: Revolution Dance offers a comprehensive program of activities for children and adults including various forms of physical fitness, dance and movement. We make every effort to ensure the safety of our students. In the highly unlikely event that my child should sustain injury during the program, I will not hold Revolution Dance, or any of its staff members liable. We reserve the right to release a child from class for non-payment, behavior issues or low enrollment. By my signature on the registration form, I understand and agree to the above policies.


Parent/Guardian Name:
Parent/Guardian Name to serve as signature:
Date: