the school › Registration Form

If paying by check, please PRINT this form. Make check payable and mail with form to:
Djanbazian Dance Academy
2600 Foothill Blvd. Suite # 102
La Crescenta, CA 91214

Child's Last Name

Child's First Name

My child is currently enrolled in (if applicable):

Age: Birth Date (MM/DD/YY)

Parent/Guardian's Last Name

Parent/Guardian's First Name

Mailing address 1:

Mailing address 2:

City State/Province Zip

Country

Telephone (day) (evening)

Has your child ever been a student with us?

How much previous dance experience does your child have?

Does your child have any specific medical or physical problems?

CLASSES:
	16 Sessions	45 minutes	$185.00

	16 Sessions	1 hour	$200.00



Class Day Time			$

Class Day Time			$

Class Day Time			$

Sub-Total			$

If you registered for more than one class take 10% off			-$

Total			$

I am printing this page and enclosing a check.

Please wait for confirmation page after clicking Submit.
If you do not see a confirmation page, please call 818.248.4458 immediately