Director’s Home

National League of Junior Cotillions
Pine Belt Chapter

Registration

REGISTRATION NOW OPEN

Greater Pine Belt Chapter

We are so pleased you have decided to enroll your son or daughter in National League of Junior Cotillion, Greater Pine Belt Chapter for this Season. We are very proud and excited about this wonderful program we offer our area.

FOR THE 2024-2025 CoTillion Season

YOU CAN ALSO LIKE US ON FACEBOOK for UPDATES AND ADDITIONAL INFORMATION!

WWW.FACEBOOK.COM/NLJCHPBC

Registrations may be completed online.

When you are registering, please be sure and select the Pine Belt Chapter on the classs that you are registering for on the drop down menu on this line item.

TUTION

Membership dues for Year I are: $340. Dues for Year II are $360 and include all costs for the training and ball pluse the instructional dinner. Dues for Premiere are $360. We highly recommend that you send in your reservation early, as class sizes are limited and are filled on a first come first-come first-serve basis. Payments can be made online using PayPal at www.nljc.com/chapter/pinebeltms and they do charge a fee for this, or checks made to Greater Pine Belt Chapter. Please put your child's first and last name in the memo line and mail to our address below. Tuition may be paid in full with the application or half with the application and the remaining half by September 1, 2024 There will be no refunds except in the case of extraordinary circumstances such as moving or illness, in fairness to students who are placed on the waiting list. Payment plans customized to fit your budget are available. There is a discount for multiple children enrolled. Please contact the Director for the details.

Roma R. Graham

NLJC Director

122 West Canebrake Blvd.

Hattiesburg, MS 39402.

Please Contact Our Director If There Are Any Changes In Address or Contact Information After Registering.

2022-2023 Student Information

Class Registering For*

First Name*

Last Name*

Preferred Name*

Gender * Male Female

Salutation

Street Address *

City *

State *

Zip *

What school will the student attend in the fall *

What elementary school did the student attend*

Current Grade *

Grade Entering In Fall *

Birth Date (format: 5/13/2011)

Add additional child to this registration »

About the Parents

How did you hear about us?

Parent / Guardian 1 Salutation

Parent / Guardian 1 First Name *

Parent / Guardian 1 Last Name *

Parent / Guardian 1 Email Address *

Parent / Guardian 1 Email Address (Again)*

Parent / Guardian 1 Cell (or Preferred) Phone *

Parent / Guardian 1 Occupation

Parent / Guardian 2 Salutation

Parent / Guardian 2 First Name

Parent / Guardian 2 Last Name

Parent / Guardian 2 Email Address

Parent / Guardian 2 Cell (or Preferred) Phone

Parent / Guardian 2 Occupation

Photo and Video Release*

Please use the checkbox below to grant permission to the National League of Junior Cotillions and National League of Junior Cotillions Pine Belt Chapter to use photos and/or videos taken at NLJC events for any legal use, including but not limited to newsletters, publicity, and web content, UNLESS I notify the director, Roma Graham, in writing (with instructions and a photo of the child) before classes begin. The National League of Junior Cotillions will not use names or identifying information about students in any publication.

As the parent/guardian, I GIVE permission for images of my child(ren) to be used by The National League of Junior Cotillions in print or electronic materials as indicated above.

As the parent/guardian, I DENY permission for images of my child(ren) to be used by The National League of Junior Cotillions in print or electronic materials as indicated above.

Allergies * I understand the director will not be held responsible with respect to accommodating food-born allergies.

Note to Director

Payments I'll pay with PayPal* I'll pay by check

*an online handling fee of 4% will be added to PayPal payments.

Younger Siblings

We attempt to ensure that younger siblings receive an invitation to participate, once they have reached the appropriate age for cotillion classes. If interested, please provide some information about younger siblings.

Sibling 1 First Name

Sibling 1 Last Name

Birth Date

Year entering fifth grade *

Elementary school child will attend

Sibling 2 First Name

Sibling 2 Last Name

Birth Date

Year entering fifth grade *

Elementary school child will attend

Sibling 3 First Name

Sibling 3 Last Name

Birth Date

Year entering fifth grade *

Elementary school child will attend

Sibling 4 First Name

Sibling 4 Last Name

Birth Date

Year entering fifth grade *

Elementary school child will attend

Please note: If your child has any special dietary restrictions or any conditions that would restrict their ability to participate in cotillion activities, please contact the director with those details.

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Director’s Home

National League of Junior Cotillions
Pine Belt Chapter

Registration

REGISTRATION NOW OPEN

FOR THE 2024-2025 CoTillion Season

YOU CAN ALSO LIKE US ON FACEBOOK for UPDATES AND ADDITIONAL INFORMATION!

WWW.FACEBOOK.COM/NLJCHPBC

Please Contact Our Director If There Are Any Changes In Address or Contact Information After Registering.

2022-2023 Student Information

2022-2023 Student #2 Information

2022-2023 Student #3 Information

2022-2023 Student #4 Information

2022-2023 Student #5 Information

2022-2023 Student #6 Information

About the Parents

Younger Siblings