Sally Gould Dance Center
321 Boston Road
Billerica, MA 01862
Registration Form/Automatic Payment Consent Form
Student's Last Name: ________________________ Student's First Name: _______________________
__ M
__ F
Student Birthdate: _____________________
Age: __________
Month
Day
Year
Mom's Name: ________________________________
Dad's Name: _________________________
Cell #: _______________________________
Cell #:_________________________
Phone #: ____________________________ Work/Emergency Phone #: ________________________
Address: ___________________________________________________________________________
Street
City
State
Zip Code
Email Address: ______________________________________________________________________
Where did you last study? ______________________ Class: ____________________ # of Yrs: _____
How did you hear about us? ___ Newspaper ___ Website ____ Referral - Other__________________
Method of Payment – Will begin October 2013
Please enclose September's tuition and registration fee of $30 per family by cash or
check. This is non-refundable.
Tuition is based on a 35 week session of classes. Your tuition will be divided into 9 ½ installments.
___ Checking Account – Attach Voided Check
___ Visa ____ Master Card ____ Discover ___________________________________
Card Number
__________
Exp Date
Card Holder's Name ____________________________________________________________
I hereby authorize Sally Gould Dance Center to charge my account in the amount of
$ _________ on the first day of each month starting October 2013 and ending May 2014
Please note: May's payment will include the ½ month of June as well
Cash Payments: If you prefer to pay cash, you may do so in 3 installments due
September 1st, December 1st, and March 1st.
___ 3 cash installments due September 1st, December 1st, and March 1st
All charges will appear as Sally Gould Dance Center. I will give the office 1 month's written notice
from the first of the month to discontinue these charges.
_______________________________________
Signature
CLASSES PER STUDENT
Toddler Time
TUITION
9 ½ Payments each of:
$30
Preschool, Kinderdance, Ballet/Tap Ages 4-6, Hip Hop Gym 5 ½ – 6
$43
45 Minute Class
$46
1 Hour Class
$50
Basic Program (6 classes)
33% discount
$195
Unlimited (7+ hours)
45-50% discount
$205
Unlimited w/Hip Hop
50% discount
$215
Family Discounts: 2 Classes – 5% off 2nd class, 3 classes 5% off total, 4 classes – 10%,
5 classes – 15%, 6 classes 20%
Class I ___________________________ Day: ___________________ Time: _________________
Class II ___________________________ Day: ___________________ Time: _________________
Class III ___________________________ Day: ___________________ Time: _________________
Dance Polices and Procedures
Payment of Fees: Tuition must be paid by automatic bank account debit or automatic credit card
payment.
Payment of Automatic Bank Account Debit or Automatic Credit Card Charge:
Tuition will be debited from your bank account on the 1st day of each month from October – May or
charged to your credit card the 1st day of each month. The month of September and the registration fee
is non-refundable. You must sign an auto-debit or automatic credit card charge authorization form.
Credit card or bank debit payments are not accepted for in-person payment on a monthly basis.
Payments must be made by pre-authorized automatic monthly payment or cash payments prior to the
first of the month. In the event of a NSF check or a declined credit card, I hereby authorize Sally Gould
Dance Center to electronically debit my account for the amount owing plus $20 processing fee.
Company parents will receive separate invoices for competitions and conventions..
Costume Fees: Costume deposit for the year-end performance will be billed to your SGDC account
and will be due by November 15th. Costume remaining balances will be a separate payment in January
and will be due by January 15th. Costume fees are non-refundable even if a student withdraws from the
school. Costume deposits and balances will be seperate payments and will not be automatically
withdrawn from your account on file.
Withdrawal and Refunds: One-month notice from the first of the month is required to discontinue
any classes. Withdrawal must be done in person and will not be accepted over the phone. Withdrawals
must be done at the school office and not with the teacher. Withdrawal must be received within the first
7 days of the month. No withdrawals will be accepted after April 1st. To withdraw from classes, a
parent or adult student must:
1. Inform school administration in person, and
2. Complete and sign withdrawal form provided by the school office.
All automatic bank debiting or credit card charges will stop after the one-month notice period. Sally
Gould Dance Center reserves the right to terminate lessons to any students without notice. In such a
case, a refund for unused lessons will be given.
Extreme Weather or Unexpected Interruption of Classes: Because we are unable to predict the
weather, we have decided to offer our students the opportunity to attend 2 additional classes prior to
January 1. No refunds for lessons missed will be given. Any weather related cancellation will be
announced on the school's answering machine.
Substitutions: The school reserves the right to provide a substitute teacher if the regularly scheduled
teacher is ill or otherwise unable to teach classes.
Attendance and Lateness: The school reserves the right to have students who come late to classes, sit
out the class. Students with repeated lateness or excessive absences may result in termination of
classes.
Injuries: The studio and the instructors are not liable for personal injuries or loss of, or damage to
personal property. Since this is a physical activity, injuries may occur. Each student may decline to
participate in any activity that they deem to place them at risk of injury and is also responsible to
inform the instructor of any limitation that may prevent full participation in class.
Photo Release: The school is hereby granted permission to take photographs of the student to use in
brochures, web sites, posters, advertisements, publications and other promotional materials the school
creates. Permission is also hereby granted for the school to copyright such photographs in its name.
I have read and understand the above policies and procedures and agree to abide by them.
______________ ______________________________ _________________________________
Date
Student Name (please print)
Signature of Parent or Adult Student
Date registered: __________________
Date entered: ____________________
OFFICE USE ONLY
Payment Received: _________________ Check #: __________
Entered by: ________________
Sally Gould Dance Center – 321 Boston Road Billerica, MA 01821 – www.sallygould.com – (978) 667-9115