Philamena’s School of Dance
Now at Maple Hills Montessori on Toronto Street in the heart of the downtown
Registration Form (January Session)


Student’s name: _____________________________________________________________________

Student’s age and birthday: _____________________________________________________________

Parent: (if under 18 yrs. Of age):__________________________________________________________

Address: ___________________________________________________________________________

Medical Comments: (i.e. Allergies?  Asthma?  All information is confidential) _________________________

__________________________________________________________________________________

Pick up other than by parent authorized to: __________________________________________________

Type of Dance: ______________________________________________________________________

1st Choice Time:  ____________    2nd Choice Time: ________________

PAYMENT

MasterCard or Visa   (Please circle which card type):

Name on Card: _____________________________________________

Number: __________________________________________________

Date of expiry: ______________________________________________

Personal Cheque:

Make cheque payable to Philamena’s School of Dance.  Please, have session paid for on or before the first day of classes. 

A 25 dollar deposit is required to hold any spot up until the first day of classes.  No refunds of this deposit will be given.  To hold a spot, or for more information please, phone 730-1890.