Grace and Glory Dance Academy Registration Form Winter/Spring 2024

Winter/Spring 2024 Dance Registration
The 2024 dance season will run from January through April with a Spring recital showcase the beginning of May. All dance classes will be held in the upper room at Naselle Assemby of God.

Monthly tuition for a Little One's class or Beginner Hip Hop class is $25. A 45 minute class is $40. An hour class is $50. If a student is taking more than one class, or siblings are signed up, the tuition for each additional class will have a $5 discount applied.

Classes offered, days, and times are listed below while registering.

A $15 registration fee is due now for the season for a single child. A family registration rate with more than one child is $25.

Student 1

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Previous Dance Experience
Classes
Student 2 (if applicable)

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Previous Dance Experience
Classes
Student 3 (if applicable)

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Previous Dance Experience
Classes
Student 4 (if applicable)

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Previous Dance Experience
Classes
Name of Parent/Guardian 1
Name of Parent/Guardian 2
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Additional Info
Health Information and Medical Emergencies
Hospital/Clinic Preference
Physician's Name
Physician's Phone Number

Area CodePhone Number
Insurance Company
Policy Number
Insurance Phone Number

Area CodePhone Number
Allergies/Special Health Considerations
Emergency Contact #1
Relationship to Student
Phone Number

Area CodePhone Number
Emergency Contact #2
Relationship to Student
Phone Number

Area CodePhone Number
Waiver and Release From Liability For Dance Instruction
I, * (PRINT YOUR NAME) have chosen to have my child(s), * (PRINT YOUR CHILD(S) NAME), participate in dance instruction given by Grace and Glory Dance Academy. I acknowledge that I understand the nature of the activities my child will be participating in. In consideration of my child's enrollment in dance instruction, I understand and agree on behalf of myself and my child, to release, hold harmless, and discharge Grace and Glory Dance Academy from all claims, costs, liabilities, expenses or judgments, including attorneys' fees and court costs for any occurrences in connection with any dance instruction. I assume all risks to my child in connection with any dance instruction and further release Grace and Glory Dance Academy and Naselle Assembly of God from liability for any injury or sickness sustained by my child while he or she is enrolled in dance instruction, including all risks reasonably connected with such activity whether foreseen or unforeseen.

I understand that Grace and Glory Dance Academy is not responsible for my child or other children who are left unsupervised outside of the areas surrounding the dance studio and that Shellie will only be supervising my child when he or she is participating in scheduled dance instruction.

I understand that Grace and Glory Dance Academy or Naselle Assembly of God is not responsible for personal property that is lost, damaged or stolen while I or my child is on the church's property.

I authorize and agree that Grace and Glory Dance Academy may take and use photographs, videos or likenesses of myself or my child for sharing or advertising for Grace and Glory Dance Academy.

My signature is proof of my intention to execute a complete and unconditional waiver and release of all liability pursuant to the terms herein, and agreement as to all terms and conditions contained above. I am of lawful age and competent to sign this affirmation.
Name

First NameLast Name
Signature
Date

MonthDayYear
Date
Registration Fee

If one child is registering, please choose first fee. More than one child, family rate.

Single Child$15.00

Family Rate$25.00

Total $0.00

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Thank you for registering your child(s) for the 2024 Winter/Spring dance season! I am SO excited to see them and have lots of fun dancing!

More detailed info (class start date, what to expect, shoes and dance attire needed, etc.) will be emailed out a few weeks before class starts but if you have any questions beforehand, don't hesitate to reach out to me through email: graceandglorydance@gmail.com. Can't wait!!

Love,

Shellie
Should be Empty:

Winter/Spring 2024 Dance Registration

Health Information and Medical Emergencies

Waiver and Release From Liability For Dance Instruction

Registration Fee

*