PLEASE PRINT CLEARLY. THIS FORM MUST BE FILLED OUT COMPLETELY.
Parent or Legal Guardian’s Name: (last) ______________________________ (first) ____________________ Are you over age 18: _______
1) Child Name: (last) ____________________________ (first) _____________________ Age: ________ Date of birth: _________________
2) Child Name: (last) ____________________________ (first) _____________________ Age: ________ Date of birth: _________________
3) Child Name: (last) ____________________________ (first) _____________________ Age: ________ Date of birth: _________________
Address: __________________________________________________________________________________________________________
Town:_____________________________________ St:_______________ Zip________________
There will be a $5. charge per phone call if we do not have your email address and we need to contact you.
Email address (Print clearly please):_________________________________________________________________________
Tele: (home) ______________________________________________ (cell)___________________________________________________
work) _______________________________________________(Emergency)______________________________________________
Child # ______ Class: ____________________________________________ Day: __________________ Time: _____:_____ to _____:_____
Child # ______ Class: ____________________________________________ Day: __________________ Time: _____:_____ to _____:_____
Child # ______ Class: ____________________________________________ Day: __________________ Time: _____:_____ to _____:_____
Child # ______ Class: ____________________________________________ Day: __________________ Time: _____:_____ to _____:_____
Child # ______ Class: ____________________________________________ Day: __________________ Time: _____:_____ to _____:_____
Child # ______ Class: ____________________________________________ Day: __________________ Time: _____:_____ to _____:_____
Wendy Worth, doing business as The Academy of Dance Arts shall not be responsible or liable for any personal injury, property damage, or consequential damage which may be sustained by any student or any other person as the result of any act or omission of Wendy Worth, doing business as The Academy of Dance Arts or any of the agents, servants, employees, or instructors on the premises of The Academy of Dance Arts or otherwise.
I understand that the child I am registering has a one month trial period. After that time I am committing to complete and pay for classes through June. If I do not fulfill my payment obligations I also agree to reimburse Wendy Worth, doing business as The Academy of Dance Arts for legal expenses.
X_________(please initial)
Tuition fees are due the 1st of every month (with a grace period until the 7th day of the month). I agree to pay a $5.00 per WEEK, $20. per month late fee.
Wendy Worth, doing business as The Academy of Dance Arts, has my consent for all purposes and/or use of photographs of the above registered student(s) with or without the use of names.
My child does____ does not _____ have special needs. Please list anything medical or otherwise we should know on the back of this form.
X________________________________________________ Date: __________________
Signature of student, 18 yrs. or older, and/or parent or legal guardian
NO PERSON WILL BE PERMITTED INTO CLASS WITHOUT A SIGNED FORM.
| FOR COMPANY USE. PLEASE DO NOT WRITE BELOW THIS LINE |
| DATE: |