Registration Page - (please register with this schedule - Click here!)

Complete the form below and pay when you come in, or
Download the Registration Form (Word .doc, 55K)
Family / Household Last Name:
Main Contact Person Name:
Address:
Suite/Apt.#
Town:
State:
Zip:
Phone (H):
Phone (W):
Phone (C):
Email:
Emergency Contact:
Emergency Contact Phone:
Medical Info Student / Member Name Adult / Child Memberships Classes Total
1.
2.
3.
4.
5.
6.
7.
8.
+ Add More Family Members
Eligible for Blue Cross/Blue Shield Discount for Fitness/Boxing Memberships? Yes No Subtotal:
Discounts: 2 Members (5%); 3 (10%); 4 (15%); 5+ (20%) Discount Rate: Discount:
Dance Class Make Up Policy: All dance classes must be paid for the entire month. There are no refunds for missed or canceled dance classes for any reason. However, students who miss a class may make up the class by taking any other class of the same level within one month of the missed class. Due Next Visit:
1Registration Fee: An annual $20 registration fee per family / household is required. Registration Fee1:
Pay when you come in via debit, credit, or check payable to "The Ninth State."