MARITIME DANCE ACADEMY
Registration for Children & Adult Programs 2021-2022
How did you hear about us? □Returning Student □Referral Name □Web Page □Billboard □Birthday Party □Other
Student Name (First and last)
First Preference
Second Preference
Health Concerns/Limitations
Email Address: *This will be used for communication and e-payment receipts, please print clearly
Emergency Contact (Other than above)
Name: Phone: Relationship to Student:
□ I have read and will abide by the COVID19 protocols.
□ I agree to by all rules, regulations and conditions contained herein or which may be posted from time to time.
□ I agree that all exercise and use of any and all facilities/services are undertaken by member at his/her sole risk and responsibility and member
further agrees that the Academy shall not be liable for claims, demands, injuries, damages or actions. Member expressly and forever releases
the Academy, its management, employees, directors or instructors from all claims, demands, damages, actions by myself, my children or
dependents, by reason of the use of any and all facilities.
REFUND POLICY: The registration fee of $30+tax (family registration = 40+tax) & costume rental fees are non-refundable. A refund or
payment reduction will not be offered for classes not attended.
Students may be able attend make up classes at either studio location. (Makeup classes may be limited during COVID19 restrictions).
Registration is for the year ending in June, payable in installments due on the following dates: 10 weeks due August 5, October 28,
January 20, and 11-12 weeks due March 31. The annual costume rental fee is due with the Oct 28th payment. All exam fees will be due
December 1
st
. Tuition is non-refundable after the due date for each installment.
The member agrees to pay $30.00 service charge for returned cheques. MDA reserves the right to cancel any class by refunding the initial fee
and any unused dues. Late payment fees are $10+tax for each additional week not paid. If a member chooses to pay fees using automatic
payment, it is the member’s responsibility to provide MDA with updated credit card information.
□ I understand and agree to the fees and payment schedule.
Staff Initial:Sign or type name to indicate agreement: __________________________Date:________________ ___________
CREDIT CARD INFORMATION OR □ Etransfer to mdajanicem@gmail.com (include dancer name in message)
Name as it Appears on Card:
Visa/MC: EXPIRY:_____________
Cardholder Signature or typed name:
I give Maritime Dance Academy permission to bill my credit card for dance tuition and costume fees (please check one):
1
st
payment only All payments for the year (excluding exam fees)
Select Location □ Bedford
□ Halifax
