Sheila E.
Dance & Fitness Center
914 Kings Highway Haddon Heights, NJ. 08035
Bus: 1(856)310-1649 E-mail:she13@verizon.net
Application for 2011 Summer Arts Program
Child’s Full Name__________________________________ Age_________
Address: _______________________ City: __________State:____Zip:_____
DOB:_____________Height:______________Weight:__________________
Tel H#____________Cell or Work#___________E-mail_________________
Mother’s Name:_________________________ Phone:_________________
Father” Name: __________________________ Phone: ________________
The amount for the 6 weeks program is $575.00. Classes begin on Monday June 27th
Classes end on Friday August 5th . Hours are from 9:30am - 4:30pm.. *Special arrangements and a small fee can be made for early drop off and / or late pick up. (As early as 6:30am and as late as 6pm.)
Enclosed is my application fee of *25.00 Check MO
Credit Card#____________________EXP_____Code on Back :_________(circle one)
(This payment reflects my non refundable application fee.)
I understand if I register on or before April 30, 2011. My registration fee is $15.00.
(That is a ten dollar discount.) $______________________.
After April 30th, my summer registration fee will be in the amount of ($25.00) __________.
I will be needing special arrangements for my child. I will discuss these at registration. Yes____ No____.
I will read the Rules, Terms and Conditions with fully understanding the agreement, and will amply comply with all of the stipulations information when given at registration time.
__________________________ _____________
(Parent/Guardian sign) (Date)
I am not interested in the summer program. I am registering my child for the fall of 2011 - 2012. I am taken advantage of the $10.00 discount and paying ($15.00) instead of the $25.00 before the July 30, 2011 deadline. $______________.
(I understand that once I send in my registration fee it is non refundable.)
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