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  __________________       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)