Registration Form

Student Name*

First NameMiddle NameLast Name

2nd Student Name (if applicable)

First NameMiddle NameLast Name

Parent Name*

First NameMiddle NameLast Name

1st Student Birth Date*

MonthDayYear

2nd Student Birth Date (if applicable)

MonthDayYear

1st Student Gender*

2nd Student Gender (if applicable)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile Number*

Parent E-mail*

example@example.com

Phone Number

Work Phone Number

1st Student Grade

2nd Student Grade

Which Studio Location*

Mobile Provider*

Class List*

A 5-6-7-8 Dance Company will keep a credit or debit card on file. If you prefer to pay cash, you may make your payment before the 22nd of any month. If we have not received payment, the card on file will be charged. There will be a $15 late fee for cards that are declined.

Please be sure to provide A 5-6-7-8 Dance Co. with your credit/debit card information. We currently do not accept American Express. You may either call, text or email the card information. Or if you prefer, you may fill out the credit card form in person.

Payment Info*

Additional Comments

INFORMED CONSENT AND WAIVER OF LIABILITY

I HAVE ENROLLED MY CHILD IN A PROGRAM OF PHYSICAL ACTIVITY INCLUDING, BUT NOT LIMITED TO, DANCE,MOVEMENT, EXERCISE, TUMBLING AND BASIC MOTOR SKILLS (JUMPING,HOPPING,GALLOPING, SKIPPING, RUNNING). I UNDERSTAND THE INHERENT RISKS, INCLUDING INJURY, THAT MAY RESULT IN MY CHILD’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’S ENTRY IN ACTIVITIES SPONSORED BY A 5-6-7-8 DANCE CO. I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE INFORMATION. I UNDERSTAND THAT PARTICIPATION INCLUDES POSSIBLE EXPOSURE TO AND ILLNESS FROM INFECTIOUS DISEASES INCLUDING, BUT NOT LIMITED TO COVID-19. WHILE PARTICULAR RULES AND PERSONAL DISCIPLINE MAY REDUCE THIS RISK, THE RISK OF SERIOUS ILLNESS AND DEATH DOES EXIST. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISK RELATED TO ILLNESS AND INFECTIOUS DISEASES, SUCH AS COVID-19, EVEN IF ARISING FROM THE NEGLIGENCE OR FAULT OF THE RELEASED PARTIES.

IN ADDITION TO THE ABOVE, I GIVE MY PERMISSION TO ALLOW A 5-6-7-8 DANCE CO. STAFF TO PHOTOGRAPH AND /OR VIDEOTAPE MY CHILD(REN) DURING A 5-6-7-8 DANCE CO. EVENTS FOR THE PUPOSES OF PROMOTING A 5-6-7-8 CO. AND / OR TEACHER TRAINING. I ALSO UNDERSTAND THAT MY CHILD WILL BE SENT HOME AND WILL NOT PARTICIPATE IN ANY CLASS UNTIL DELINQUENT ACCOUNTS ARE PAID IN FULL!

I understand A 5-6-7-8 Dance Co.’s payment process and agree to allow A 5-6-7-8 Dance Company to charge my debit/credit card the amount of my child’s tuition, annual registration each August, plus any costume rental or purchase fees needed on the 22nd of each month. I understand that there are no refunds and that when canceling automatic payment, I must send A 5-6-7-8 Dance Co. a written copy of automatic payment cancelation before the 22nd of any month.

Signature

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