Office use:Date_____________

Reg. Fee†††††††††††††† __$30.00______

Tuition†††††††††††††††† ______________

Payment†††††††††††† ______________

Balance †††††††††††††† ______________

Ck#___________ Cash________

 
 

 


Center for Dance Studies
Registration Form 2015-2016

 

 

Student #1: Last Name_________________ First Name___________________ Birthdate ____________

 

School Attending___________________________________ Grade as of September 2014______________

 

Dance Class #1/Level†††††††††††††† ††††††††††††††† Dance Class #2/Level†††††††††† ††††††††††††††††††† Dance Class #3/Level

______________________††††††††††††††††††† ______________________††††††††††† ________________________

 

 

Student #2: Last Name_________________ First Name___________________ Birthdate ______________

 

School Attending___________________________________ Grade as of September 2014______________

 

Dance Class #1/Level†††††††††††††† ††††††††† Dance Class #2/Level††† ††††††††††††††††††† Dance Class #3/Level

______________________††††††††††††††† ______________________ †† ________________________

 

 

Student #3: Last Name_________________ First Name___________________ Birthdate ______________

 

School Attending___________________________________ Grade as of September 2014______________

 

Dance Class #1/Level†††††††††††††† ††††††††† Dance Class #2/Level††† ††††††††††††††††††† Dance Class #3/Level

______________________††††††††††††††† ______________________ †† ________________________

 

 

Motherís Last Name______________________________First Name______________________________

Fatherís Last Name______________________________ First Name______________________________

Address_________________________________________City______________Zip code______________

Home telephone # (______) ________ - _____________E-MAIL:_______________________________

Motherís profession______________________ Employer___________________ work # (______) ________-_______

Fatherís profession______________________Employer___________________ work # (______) ________-________

 

Person responsible for billing: ______________________other, name:____________________________

Address, if different from above _________________________________________________________________________________

 

I hereby agree to participate/have my child participate in YDRís dance classes.I recognize the physical risks inherit in any dance program and I hereby agree to indemnity and hold harmless YDR and its instructional staff from any and all claims, costs, liabilities, expenses and judgments arising out of participation, or illness/injury therefrom.I also hereby give YDR and its staff and authorized officialís permission to take photographs and make videotapes of my child while he/she is participating in classes and/or performance activities for the purposes of educational processes, fund-raising, public relations, and other specific reasons as deemed appropriate by the organizationís Directors.

 

CONSENT FOR EMERGENCY MEDICAL TREATMENT

I do hereby give authority to YDR and its staff to obtain necessary emergency medical treatment for my child/myself with the understanding that the family will be notified as soon as possible.

 


Registering Parent/Guardian Signature: _____________________________________†† Date:_____________________

I hereby agree to participate/have my child participates in YDRís dance classes.I recognize the physical risks inherit in any dance program and I hereby agree to indemnity and hold harmless YDR and its instructional staff from any and all claims, costs, liabilities, expenses and judgments arising out of participation, or illness/injury there-from.I also hereby give YDR and its staff and authorized officialís permission to take photographs and make videotapes of my child while he/she is participating in classes and/or performance activities for the purposes of educational processes, fund-raising, public relations, and other specific reasons as deemed appropriate by the organizationís Directors.

 

CONSENT FOR EMERGENCY MEDICAL TREATMENT

I do hereby give authority to YDR and its staff to obtain necessary emergency medical treatment for my child/myself with the understanding that the family will be notified as soon as possible.

 

Registering Parent/Guardian Signature: _____________________________________†† Date:_____________________