2019-2020 REGISTRATION FORM

You may print out this form and return it via fax or mail to your specific LPCW Regional Office or drop it in
the LPCW drop bag at your child’s daycare, preschool, or studio. Please be sure to fill the form out
completely, sign it, and include appropriate fees. PLEASE NOTE: tuitions can vary by region…please
confirm correct tuition amount with the director of your region.

CHILD’S NAME: AGE:

BIRTHDAY:

DAYCARE/SCHOOL NAME: Location:

PARENTS’ NAMES:

ADDRESS:

City: State: Zip:

PHONE: (h) (w)

Cell phone: e-mail:

**E-MAIL IS REQUIRED—THIS IS HOW WE DELIVER MONTHLY NEWSLETTERS!
My check or money order is enclosed for $__________. ($25 registration fee and first month's tuition.)

Please charge my: (circle one) MC VISA VISA CHECK

Name as it appears on card:

Card #: - - - Exp. Date:

Charge Amount:

Authorized Signature:

Please charge this card monthly for my child’s tuition. I understand this will be done on the 15th of the
preceding month tuition is due; and in order to withdraw from auto payment I must submit a request in
writing prior to the 15th of the month.

Yes, I would like my child to take dance with LPCW. I have read and understood the policies and agree to abide by them. I,
the undersigned, also release the daycare/preschool/studio; as well as LPCW and its directors and instructors as responsible
for any loss or injury the child listed above may incur while taking this special class. I also give LPCW permission to use any
pictures taken during LPCW classes of the child listed above within their media outlets. I understand my child is registered
through August 2020.

Parent or Legal Guardian’s Signature Date

Please enclose $25 registration fee + first month's tuition along with completed registration form.
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