DanZ Company Registration Form

Student Information

1 entry per student required
Student Name*

First NameLast Name
Student Birth Date*

MonthDayYear
MaleFemale
Student Residence Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you were referred by someone, please provide the name below:

First NameLast Name
Can the student leave the workshop by him/herself without a guardian?*

Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian E-mail*
example@example.com
Parent/Guardian Contact Number*
Format: (000) 000-0000.
Parent/Guardian Alt. Contact Number
Format: (000) 000-0000.
Adults Authorized For Student Pick-up

If the student is not allowed to leave the class by him/herself (as indicated in previous page), the student will only be released for pick-up to the Parent/Guardian as indicated above and adults on this list. A photo ID is required to confirm identity.
Authorized Adult's Name #1

First NameLast Name
Contact Number #1
Format: (000) 000-0000.
Authorized Adult's Name #2

First NameLast Name
Contact Number #2
Format: (000) 000-0000.
Authorized Adult's Name #3

First NameLast Name
Contact Number #3
Format: (000) 000-0000.
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Emergency Contact's Phone No.*
Format: (000) 000-0000.
Emergency Contact's Alt. Contact No.
Format: (000) 000-0000.
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe. Otherwise, please indicate "Not Applicable" or "N/A".*
Is the student prescribed an inhaler? If yes, please explain any instructions. Otherwise, please indicate "Not Applicable" or "N/A".*

Media Release
Do you give permission to use the above student's identifiable image or likeness to promote Bel canto Studio (hereafter referred to as Organizers) programs in all forms, media, and manners, including but not limited to news releases, photographs, video, audio, website, marketing, advertising, and promotion for an indefinite period of time?*
I hereby grant the Organizers permission to use the above student's identifiable image or likeness to promote the Organizers' programs in all forms, media, and manners, including but not limited to news releases, photographs, video, audio, website, marketing, advertising, and promotion for an indefinite period of time.

I give unrestricted permission for images, videos, and recordings of the student to be used in print, video, digital, and internet media. I agree that these images and/or voice recordings may be used for a variety of purposes and that these may be used without further notifying me.

I further acknowledge that I will not be compensated for these uses and the Organizers own all rights to the images, videos, and recordings and to any derivative works created from them.

I waive any right to inspect the uses of any printed or electronic copy. I hereby release the Organizers from any claims that may arise from these uses, including without limitation: claims of defamation or invasion of privacy, or of infringement of moral rights or rights of publicity or copyright.

This Release expresses the complete understanding of the parties.
I understand that if I do not agree to the above, the Organizers will avoid including the student in any media to the best of their ability, and will edit my child's identifiable image/likeness out of any media in which they do appear.

This Release expresses the complete understanding of the parties.
Informed Consent and Acknowledgement

As Parent and/or Guardian of the named student, I hereby give my approval for the student’s participation in any and all activities prepared by the Organizers during the selected sessions. In exchange for the acceptance of said student’s candidacy by the Organizers, I assume all risks and hazards incidental to the conduct of the activities, and release, absolve, and hold harmless the Organizers and all its respective officers, agents, and representatives from any and all liability for injuries to said student arising out of traveling to, participating in, or returning from selected sessions.

In case of injury to said student, I hereby waive all claims against the Organizers including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the student, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the student’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination, and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Organizers and its affiliates including Teachers, Volunteers, and Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
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.
Date

MonthDayYear
Date
Signature

Bel Canto Studio DanZ Company Tuition

Email will be sent once the minimum number of students is met. Payments will then be adjusted accordingly.

$375.00CAD for the first payment then,$320.00CAD for each two months

Enter coupon

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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Student Information