Eleanor Pernia Dance Studio Registration
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Eleanor Pernia Studio of Dance


Registration Form


Please print out this form. Fill it out and send it in with your payment.

Eleanor Pernia Studio of Dance
10434 BALTIMORE BLVD.
BELTSVILLE, MD 20705
Call at: 301-937-4230

 

Name of  Student_________________________________ Date of Birth ___________________

Name of Parent__________________________________________________________________

Address________________________________________________________________________

City______________________________ State__________________  Zip__________________

E-mail address:_______________________

Home phone ____________________  Cell phone________________  Work phone_____________

Class desired ___________________________

Payment for class         ________________

Registration Fee           ___________$35__

Total Payment enclosed ________________

Mail this form to:
Eleanor Pernia Studio of Dance
10434 BALTIMORE BLVD.
BELTSVILLE, MD 20705

or deliver it to the studio and drop it in the mail slot.

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10434 Baltimore Blvd, Beltsville, MD 20705; Call at 301-937-4230