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Class Enrollment Form-Xtreme
___________________________________________DOB ___/___/_______ Age
Person Responsible for Account
Last 4 of Social ______________ DOB _______________
The information above is kept private and
confidential. This information is only used for collection purposes on bad debt.
Emergency Contact (Separate
from adults named above)
________________________________________ Number: ______________________________
How did you hear about us?
______________ Referred By: ______________________________
Does this student have any medical conditions we
should be aware of? Y N Explain
XDA does not carry medical insurance for its
students. Each student is required to be covered by their own family medical policies, and if any injury occurs it
is understood that the student’s own policy is their only source of
Risk:It is understood that you are registering for a sport and there is the possibility of
injury in the event of an accident.
Registration fee: Required of
all New and Returning students. Class space is not held until registration fee is
Late Fee on Tuition
is $15.00 – added to account after the 1st Day of each month
Fee-Sweatshirt-Attire for Class / All other Mandatory Fee’s: See Calendar or Online
Added to accounts that go over 90 days & are added each month to balance until paid in
You’re responsible for all fee’s the studio may acquire during a collection process.
XDA Reserves the
right to terminate any student enrollment due to non-payment if balance is unpaid after 90
Students are assessed a $25 Drop Fee if you drop after the Enrollment Closing Date: See
are assessed a $100 Drop Fee After 1st Week of Company Season
· Any dancer causing difficulties in class will be asked to leave at the
· Students are not allowed into class without the proper required attire.
This includes; clothing, hair and shoes
· No food, candy, or drinks other than water is allowed into the dance
room unless otherwise cleared through the staff.
· Any item lost or stolen in the studio or parking lot is not the
responsibility of XDA.
· All photo’s taken by Xtreme Dance Academy are the property of XDA and
can be used for promotional purposes. If you do not allow photographs to be taken of your child please
initial here __________
· All students participate in the Mebane Christmas Parade.
· Selected Students attend and participate in the Mebane Dogwood
· All families are required to read through the Studio
FINANCIAL AGREEMENT & AUTO DRAFT FORM MUST BE SIGNED TO COMPLETE
Signature: __________________________________ Date: