12th Annual Debbie Allen Dance Institute

June 6 thru June 19, 2010

Student Name:
Street Address:
City:
State:
Zip Code:
Telephone:
Cell Phone:
Age:
Birth Date:
T-Shirt Size:
Last School Attended:
Gender:
Parent/Guardian Name:
Home Phone:
Work Phone:
Cell Phone:
e-mail address:
Street Address:
City:
State:
Zip Code:
In Case of Emergency Call
Name:
Phone:
Relationship:
Physician's Name:
Phone:

Tuition $500.00
Application Fee $25.00 (non-refundable)
Total $525.00

A $100 deposit and a $25 application fee must accompany each completed registration form. Tuition balance of $400 due June 6, 2010.

Early Bird Special
$75.00 off tuition if balance is paid in full by March 31, 2010.

Please make check or money order payable to Imagination Celebration Fort Worth.

Imagination Celebration
1300 Gendy #210
Fort Worth, Texas 76107

Call the ICFW office for Credit Card Payment - 817.870.1141

By participating in the Debbie Allen Dance Institute I grant Imagination Celebration Fort Worth permission to use, publish, and display for any legal purposes in order to provide information about ICFW, any or all photographs, videos, or descriptive text in which I or the Minor(s) whom I am responsible for appear(s).

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