Eleanor Pernia Studio of Dance

Registration Form

 

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           ___________$22__

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.