-------------------------------------------------------------------------------------------------------------------------------
Eleanor Pernia Studio of Dance
Registration Form
Please print out this  form. Fill it out and send it in with your payment.

Name of  Student_________________________________ Date of Birth ___________________

Name of Parent________________________________________________________________

Address______________________________________________________________________

City_____________________________ State__________________  Zip__________________

E-mail address:_______________________

Home phone_________________________ Cell phone_______________  Work phone______________

Class desired ___________________________         Payment enclosed ______________________
                                                                                     (please enclose the $22.00 registration fee)

Mail this form to:
Eleanor Pernia Studio of Dance
10434 BALTIMORE BLVD.
BELTSVILLE, MD 20705
or deliver it to the studio and drop it in the mail slot.

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Home / Teachers / Schedule / Tuition / Registration / Student Information /Classes / Photos / Directions