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Student:_______________________________________________
Age:________________________D.O.B_____________________
Parent(s):_______________________________________________
Address:_______________________________________________
City:_____________________________
Zip:_________________
Home phone:________________ Cell/Work:__________________
Email:______________________________
Childcare
Center:______________________________
Location:_______________________________________________
(Name of street, road or highway)
Please check program preference for your child's school.
Acceptance is subject to course availability. Call
678-482-2264 or check with your child's school for specific
programs offered there
Pre-Ballet:_____
Tap-Ballet:_____ Pre-Gym:_____
I have read and understand the information provided in
this website. I waive any
right to claim against Creative
Movement and Dance, Inc. owners, staff, and teachers
in the event of accident, injury or loss of personal
items. To review policies, click
here.
Signature:__________________________________Date:___________
Pay by
Credit Card: Visa / Mastercard (please circle)
Card Number:_____________________________________
Exp. Date:______________________________________
Amount to pay:__________________________________
Click here for
Monthly Billing Authorization Form
(Requires Adobe
Acrobat Reader
 )
Fax Number: 678-482-7064
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MAIL THIS PAGE WITH
$48.00 FIRST
MONTH’S TUITION AND $30.00 REGISTRATION FEE ($78.00)
PAYABLE TO:
CREATIVE MOVEMENT AND DANCE
P O BOX 2127
SUWANEE, GA 30024
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