Tapping with Tina’s Ballerina’s Registration Form
Student’s Name
Student’s Age & Birthday
Parent’s Name
Address with zip code
E-Mail Address:
Home Phone #
Work Phone #
Cell Phone #
School & Day You are Interested In:
Referral Source:
Does your child have any allergies? No Yes
May your child have candy & holiday treats?
Yes
Yes (except for above allergies)
No
Additional Comments (please note any health conditions):
**Office Use Only**
Registration Fee
$ #
Costume Deposit
**Ms. Tina Only**
**Office Use Only**
**Office Use Only**
Sept.
$ #
Dec.
$ #
Mar.
$ #
Oct.
$ #
Jan.
$ #
Apr.
$ #
Nov.
$ #
Feb.
$ #
May.
$ #
$ #
Costume Balance
$ #
Recital Fee
$ #
Please Write ALL Checks Payable to: Tina Stemmler
***Also Include on the Check—Memo: Students Name
If you wish to mail your registration form and payment, please enclose:
Registration Form
Payment
Any Coupons
Mail to:
Tapping with Tina’s Ballerinas
PO Box 191164
St. Louis, MO 63119