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)

* 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