DANCE for Special Needs Class Registration Web Site Child's Name * Child's Birthday * Parent's Name * Street Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Email Address * Contact Number * Saturdays, September 21-December 8 (No class Nov. 23 or Dec 7, last class Dec 14) * Saturday 2:15-2:55pm [ages 5-7] Saturday 3:00-3:45pm [Level 1. new students ages 8-12] Saturday 3:30-4:30pm [Level 2, returning students ages 8-12] Saturday 3:30-4:30pm [Level 2, ages 13 and up] Classes are held at the Academy of Dance by Lori taught by Michelle Dawson, Co-director and staff Please indicate your child's diagnosis or area of need: * Downs Syndrome Autism Spectrum Disorder If not listed, please specify: * Photo Release The Academy of Dance by Lori periodically takes photos and videos of classes for training, promotions, and social media outlets. Student's personal information (i.e. last name, age, etc.) will never be used. If you do not wish to have your child's image used by Academy of Dance by Lori, you must inform us in writing by emailing mdawsondance@hotmail.com. * Consent I hereby release the staff, their agents, the servants, and the employees of The Academy of Dance by Lori, Inc. 1775 N. Highland Rd. Pittsburgh, PA 15241 and the premises upon which the event or class is being conducted, from damages regarding injury or property loss sustained during or in connection with The Academy of Dance by Lori, Inc. All deposits are final. No refunds or credits will be given for any items ordered, including fall registration fees, tuition payments or deposits, costume deposits, seamstress deposits, summer classes, Choreography fees, logo, or accessories, recital costumes etc. Parents are responsible for full payment once items are ordered or deposits are made. All sales and deposits are final and non-transferable. Parents are also responsible for all payments in full if a deposit was made and a balance is remaining of any accounts. * Signature (Full Name) * Information Summary Class Total Total:
