Enrollment Form 2009-2010
Student Name:
Date of Birth:
Address:
Email:
Name of Parent
or Guardian:
Phone #
Referred by:
_______________________________________________________________________________________
DANCE
Dance Combo
Jazz
Ballet
Baton Twirling
Cats- Spring
Hip Hop
Dance Ensemble
Dance Costume Fee
_______________________________________________________________________________________
MUSIC
Mary Grovola - ALMOST FULL
Tom O'Connor
Ed Ryan - ALMOST FULL
Paul Lewis - ALMOST FULL
Jason Leonard
Shane Munzert -Associate Teacher
Lesson Length
livecafe@pca
_______________________________________________________________________________________
THEATRE
Theatre Classes
Musical Theatre Ensemble
Footloose
Broadway  Cabaret
Theatre Costume Fee
_______________________________________________________________________________________
Adult Fitness
Adult Fitness
_______________________________________________________________________________________
Total Amount Due
(Please include $25 Reg
Fee)
Credit Card #:
Exp. Date:
Security Code
(3 or 4 digit code)
Additional
Comments:
I would like to be set up on an automatic payment plan.
I am making a payment on my monthly tuition.
By checking the statements below and entering your name in the "signature" box, you are
indicating in writing, your agreement with the terms and conditions of this enrollment.  
Thank you!
I hereby accept all responsibility for any accident, injury, or illness
that may occur in conjunction with this program.  I am releasing
and hold harmless Premier Centre for the Arts and all other parties
involved from any and all claims, costs, liabilities and expenses
including all judgments, attorney’s fees and court costs.  Premier
Centre for the Arts provides no medical insurance for the
participants. I am executing this waiver and release for my
child/me to participate in this program.  I have read and agree to all
terms listed in this catalog.
I understand that 30 days written notice is required should I wish
to withdraw from a class and that I am responsible for all tuition up
through the end of my 30 days written notice.  There are no
refunds or credits for tuition.  A $20 late fee will be charged for all
tuition paid after the 10th of each month and a return check fee is
$35.  There will not be makeup lessons for private lessons missed by
the student. Make-up lessons will be provided for private lessons
missed in the event PCA is closed due to inclement weather or
cancellation by the teacher.
I understand that from time to time, PCA will photograph events
and classes for promotional purposes.  I give PCA permission to use
my/my child’s image and name for promotional purposes.  PCA
reserves the right to transfer a student to another class or to
dismiss a student for poor progress and/or attendance or failure to
comply with PCA policies.
I understand that there is absolutely no video recording or
photography permitted at any PCA performance.  Failure to comply
with this policy will result in ejection from the event without a
refund.  I understand that recital participation is a requirement of
PCA programs.  Students not participating in recitals will not be
permitted to register for future classes.  
Parent / Guardian
"Signature"