Amiya's Mobile Dance Academy

Please fill out the registration form completely and either submit it online or place it in the AMDA Bus Pink Mailbox in the bus. You can also fax it directly to AMDA at 313-836-1852. Please include your registration fee $15 and your first payment of 50% or full payment for 12 weeks tuition with your registration form. No Personal Checks. Company Checks, Money Orders, and Cashiers Checks should be made payable to: Amiya’s Mobile Dance Academy Please do not turn in the registration form or payment to the school or teacher, please place in AMDA Mailbox on the bus or submit it online to our office!

Student Name:* Nickname:

Age: Birthday: Male: Female:

Address: City: State: Zip:

Home phone: Parent's work/cell phone:

Email:*

Childcare facility/school: Location:

Any medical conditions:

May your child have candy/fruit snacks? Yes: No: Allergies:

Payment Plan:

DPS/Detroit Residents
Plan A – Full Payments $138.00 ($11.50/week)
Plan B – Two Payments $69 (initial & 2nd months of class remaining 50% due)

Non DPS/Detroit Residents
Plan A – Full Payments $150.00 ($12.50/week)
Plan B – Two Payments $75 (initial & 2nd months of class remaining 50% due)

Policies: Payments are due with initial application or in two payments which are due by the 4th of the child’s second month of class. A $5 late fee is assessed to all late accounts. Release and Waiver, Assumption of Risk, and Indemnity Agreement attached: 1. All students must display respect to all classmates at all times. There will absolutely be no socializing in a disruptive manner during class or food/gum on the bus. 2. My child is between the ages of 2yrs-8yrs old 3. I understand that AMDA’s Attendance Policy will be strongly enforced 4. Students must be on time to class, however I understand if my child is 5 minutes late he/she will not be allowed to participate in class. 5. I understand my child’s class is one hour and I will pick my child up on time. Any child not picked up within 15 minutes after class, parents will be contacted, if no response my child will be taken to the nearest police station. 6. I understand and will remain compliant with AMDA’s Tuition Policy 7. I understand if my child’s tuition is not paid by the 4th of every month my child can not attend class until my tuition is paid and current. 8. I understand my child should come to class prepared in uniform to help them prepare for the next level of dance a. Ballet: ( Girls; black leotard, pink tights, pink leather ballet shoes, hair in a bun/away from their face) (Boys; white T-Shirt/AMDA shirt, black shorts, black leather ballet shoes) b. Tap: (Girls/boys; AMDA T-Shirt, black dance shorts/pants, pink tights/boys socks, black tap shoes) 9. I understand if my child does not follow the dress code he/she will be asked to observe the class and not participate during that class session unless an unforeseen circumstance arises 10. I will encourage and motivate my child to do his/her very best in all classes, I will instill in my child that “A winner is not a quitter, and A quitter is not A Winner”. 11. I promise to work with AMDA to build my child’s self-esteem/confidence 12. We follow the Southfield Public School System school closings; in this case the AMDA Classes will be canceled 13. I understand this is neither a babysitting service nor a latch key program. This is an extracurricular program to introduce my child to the world of dance. 14. I understand that no visitors are allowed on the bus during class except on Parent Observation Days which will be once a month or the last 5 minutes of a class. 15. I understand that I am not allowed to interrupt classes; I will address any concerns with the dance teacher or manager before or after classes. 16. I understand my child will be taught by Amiya Alexander who is under 18 years of age and/or her assistant teachers who are over 18 years of age. I understand all staff are well trained/certified with small children and dance instructions. 17. I understand that I am committing to the AMDA program and I can withdraw my child at any time as long as I contact the AMDA Office. And I have read and agree to the policies. 18. I understand that my child will be taken to class each week unless I notify the AMDA Office otherwise. 19. I understand that if my child is absent or doesn’t go to AMDA for any reason and I do not contact the AMDA Office, I am expected to pay for that class.(Max 1 credit per month) 20. I understand that if my child is absent or doesn’t go to AMDA for any reason and I do not contact the AMDA Office, I am expected to pay for that class.(Max 1 credit per session) 21. I understand that my child’s picture may be used in promotional materials. No names will be used. I recognize that a risk is involved in participation in dance class, related activities, and that the activities require adherence to rules and discipline. 22. I received while participating or practicing in dance and its related activities. Your signature represents a commitment to the AMDA Program. You must contact the AMDA Office to discontinue enrollment. 23. Full Payment is due whether your child attends all of the classes or not. One credit per session is given for absences if we are contacted at the AMDA Office before the class. Credits do not accumulate. If we are not notified of the absence before the class, you will be expected to pay for that class. Credit will be issued on pre-paid classes if AMDA is unable to attend the regularly scheduled class due to inclement weather, mechanical breakdown, or other unforeseen problems

* I have read and understand the policies of AMDA as noted above.

Parent/Guardian Name:* Date:

* = required information

Phone: (248) 483-DANCE (3262) | Fax: (313) 836-1852 | Email Us