<p> 2623 151st Place NE Building 2 Redmond, WA 98052 425-867-2300 Email: [email protected] Web: www.premieredancecenter.com Student Last name First Name Birth date Address Street Address City State Zip Code Contact Email Address Home Phone Cell Phone Work Phone Mother or Guardian Names of family members enrolled Last name First Name Father or Guardian Last name First Name Does student have any life threatening Medical Conditions? Yes____No____Please describe______Please tell us how you found Premiere Dance Center Circle One Please Internet ● Microsoft Prime Card ● Kids Directory ● Friend’s Name______● School Packet (which school) ● Premiere Birthday Party</p><p>THE HOLD HARMLESS & FINANCIAL AGREEMENT: The undersigned member and their parent(s)/guardian(s) indemnifies and holds harmless Premiere Dance Center and its agents and officers, staff from any liability whatsoever for any damages or injuries and from any and all claims and demands including attorney fees, arising out of the parties participation in dance classes, private lessons, rehearsals and/or performances provided by or participated in, through The Premiere Dance Center. We suggest you consult your physician prior to participation. In addition ( CIRCLE ONE PLEASE I do or I do not) give permission for Premiere Dance Center Staff to authorize Emergency Medical Treatment for the above named student in the event that they find necessary. I hereby assume all Financial Responsibility for the above student enrolled at Premiere Dance Center. I further understand I will be charged for all classes until I have notified PDC in writing of my child’s withdraw from classes. In event it becomes necessary to refer this account for collection, you (as the parent/guardian) will be liable for all collection fees, including attorney fees, interest, etc. NO REFUNDS: Missed classes must be made up within session of missed class. NO CASH REFUNDS are given. NO TUITION IS TRANSFERABLE. . I HAVE READ AND UNDERSTAND THE ABOVE POLICIES X Signature (of parent if under 18) Date</p><p>Summer camps will run on the following dates from 10am to 1pm. The Cost is $227.00 per camp and includes the registration fee. Summer session times vary. Students may register for more than 1 camp/session.</p><p> 4 week Summer Session July 13 - August 8  Barbie Diamond Castle June 22-26  High School Musical July 6-10  The Secret Garden August 3-7  Summer Intensive Dance Camp August 10-14 Day Time Summer Session Class Instructor Hours to to to to Start Date Yrs of Dance Discount Type Hours Registered Per Week </p><p>Automatic Payment Authorization or Tuition w/ discount (if applicable) Payment Form Credit Card Phone Order Authorization Adult Punch Card $100.00</p><p>Credit Signature on File Deposit to hold space in class</p><p>Cash Master Card or Visa # Summer Registration Fee</p><p>Check # V-Code: CC Expiration Date Discount</p><p>By: MSPC Exp Date: Microsoft Prime Card # Total Due </p>