Shoreline Dance Registration Form

Dancer Information

Dancer's Name

First Name Last Name

Birth Date

Month Day Year

Gender

Male Female

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Parent/Guardian Information

Name

First Name Last Name

Home Number

Area Code Phone Number

Cell Number

Area Code Phone Number

E-mail

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Area Code Phone Number

Does the dancer have any allergies, chronic illness, or medical conditions? If yes, please describe.

Class/Day of the Week/Tuition

Credit Card Number Exp.
CVC

Bill Card on file Monthly for tuition?

Yes No

Your card will be automatically billed on the 10th of the month if you have not remitted payment. If your card is declined a $25 late fee will be added to your bill.

Handbook Acknowledgement

I/We acknowledge the Shoreline Handbook as posted online at www.shorelinedance.net.

Photo and Video Release

I/We grant Shoreline Dance Studio the right to take photos and videos of my child in connection with the above identified subject. I authorize Shoreline Dance Studio to copyright, use, and publish the same in print and/or electronically.

Wavier of Liability

I/We on behalf of myself/ourselves and my/our minor child, hereby release Shoreline Dance Studio, its officers, agents, and employees from all claims from injury or illness which may be sustained by my/our child while participating in dance classes, rehearsals, performances, or other dance related activities. I/We also release the Sheldon Theatre from all claims of injury or illness which may be sustained by my/our child while participating in the Shoreline Dance dress rehearsals and recital performances.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature *

Clear

Shoreline Dance Class Registration