On-line application form for Dance Program in New York

Language Course Application Form

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SUMMARY

SECTION 1. PERSONAL DETAILS

INSTRUCTIONS

Fill in the application form on-line and enclose the evaluation from your present dance teacher and any other particular requests or objectives. This documentation can be sent either by e-mail , post, or fax. Please answer all questions. All fields marked with a * are required and must be completed. Applications must be received at least 4 weeks prior to the start of the course to guarantee the best seats for the performances and placement in the dance school chosen.

Once your application has been received you will be give a reference N° that you will need to quote on all correspondence, e-mails or when contacting us by telephone.

We offer SSL on-line secure credit card

payment. For your convenience if you prefer, you can fax us your application with your credit card details. We also accept credit card payment over the phone, cheques and bank transfers.

First Name*

Last Name*

Age:*

Passport N° *

Home Tel N° (country code first)

Work Tel N° (country code first)

Mobile Tel N° (country code first)

Fax N° (country code first)

E-mail

Address Line 1*

Address Line2

City*

County/State*

Zip/Postal Code*

Country*

Next of kin (if different from above) Address Line 1:

Next of kin Address Line 2:

Next of kin City:

Next of kin County/State:

Next of kin Zip/Postal Code:

Next of kin Country:

Next of kin home Tel N° (country code first)

Next of Kin work Tel N° (country code first)

Starting date:*

Choice of dance school:*

I have studied the following dance styles:* (please state dates and weekly frequency of classes attended)

I have decided to register for this course because:*

How did you find our website?* Please quote Ref N° if applicable:

Contact address in New York:*

Contact telephone number in New York:*

SECTION 4. PAYMENT DETAILS

Your information will be kept secure and private

Pay to:

Totalnannies.com

Payment for:

Agency Fee for language

course and accommodation

abroad

Amount:

£ 99.00

Payment for:

Registration Fee

Amount:

£ 172.00

Total to be debited to your credit card:

£271.00

First Name*

Last Name*

Type of Credit Card*

Credit Card Number*

Issue Number (only Switch Cards)

Expiration Date*

Billing Address Street*

Billing Address City*

Billing Address County/State*

Billing Address Postal Code/Zip*

Billing Address Country*

For your protection, we confirm credit card billing addresses.

The process normally takes about 30 seconds, but it may take

longer during certain times of the day. Please DO NOT cancel

your submit request until you have received a final response

from the server.

By clicking "Continue", I agree to be bound by

totalnannies.com's declaration of responsibility

Declaration of Responsibility

I declare that I will not hold Dance Forum or any other member of the teaching staff responsible for injuries sustained or illnesses contracted by me whilst I am a student at the Dance Forum or another dance school included in the Dance/English Program

OTHER PROGRAM IN NEW YORK

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