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: $460/semester ~ $92/month
2.15 - 3 hours: $600/semester ~ $120/month
3 hrs 15 min - 4 hours: $675/semester ~ $135/month

Registration Fee: $15.00 per year

Pay in full by August 15th and receive a $20 discount off of your semester tuition!

Participants in all Christmas performance groups (as indicated by a * above) must pay an additional $50 recital deposit with their registration. (Separate checks please, remaining $50 balance will be due Oct. 1st)

Please choose a payment method:


Please stop by the studio to render payment.

*If you choose the monthly payment option, the August payment will be processed on August 20th. All other monthly debits will be processed on the 5th of the month.

Although we appreciate your online registration as we plan for fall classes, your child's spot in class will not be secured until payment is rendered. (Registration fee or payment in full)


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: