Alyce Carella Dance Centre 1153 New Britain Avenue West Hartford, CT 06110 860-232-7225 REGISTRATION FORM         PLEASE PRINT                                                                                                   Date__________ Student's Name____________________________________  Date of Birth________    Age____ or Adult____ Street Address __________________________________    City__________________  Zip Code__________ Home Phone ___________________ Work Phone __________________  Cell Phone  __________________    E-Mail Address ______________________________School Attends _______________________  Grade____ Parent's Name ________________________________________________________________                          Address if Different from Student ________________________________________________                              Person Responsible for Tuition __________________________________________________                               Emergency Contact  _________________________________ Relationship____________  Phone____________ Health Problems  ___________________________________________________________________________ Returning  Student  __  or New  __    Previous Dance Training – Name of School __________________________ Types of Dance _____________________________________         Number of Years _____                               I learned of the Alyce Carella Dance Centre through   __Newspaper Ad   __Yellow Pages  __Internet                                                                                                                                                                        __An Acquaintance - Recommended by ________________                       Classes Desired (ballet, tap, jazz etc.)             Day                         Time                                                                                                    ______________________________________________________________________________                                               ______________________________________________________________________________                                      _____________________________________________________________________________                                       ______________________________________________________________________________                                                            Registration Fee: $25.00 - $30.00 per family                                                                  $15.00 2yr olds        The sum of $ ______________as registration fee for ______Children                         SIGNATURE OF PARENT_____________________________   DATE______________ (or student if adult)