Ms. Patricia's School of Dance & Gymnastics Registration, Photo Waiver, & Liability Agreement

Ms. Patricia's School of Dance & Gymnastics Registration, Photo Waiver, & Liability Agreement

Complete the registration, medical & liability release, confirmation, and photography waiver details. Default all fields to optional unless required; signatures and consent/waiver dates are required.
Student Info
Student's Name - First
Student's Name - Last
Age
Date of Birth

MonthDayYear
Date
Sex
Student's Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Info
Father/Guardian Name
Father/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Father/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Name
Mother/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mother/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Tuition Responsible Party
Person Responsible for Tuition - Name

First NameMiddle NameLast Name
Person Responsible for Tuition - Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Person Responsible for Tuition - Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contacts
Emergency Contact 1 - Name
Emergency Contact 1 - Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 - Name
Emergency Contact 2 - Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical & Liability Release

Students will be permitted to take part in dance, gymnasticsand cheer activities offered by Ms. Patricia’s. I/We release Ms. Patricia’s School of Dance and Gymnastics, proprietors,instructors and sponsors from any liability of above student, to us or toeither of us as a parent/guardians for injury to above student and furtheragree to indemnify Ms. Patricia’s School of Dance & Gymnastics, proprietors,instructors and sponsors against all loss and liability which they may incur orbecome responsible for, arising by virtue of above student’s participation insuch activities and athletics.
Student’s First & Last Name

First NameLast Name
Parent/Guardian Signature
Date

MonthDayYear
Date
Email
example@example.com
Confirmation Date

MonthDayYear
Date
Photography Waiver

I am granting permission for my child to be filmed,videotaped, audiotaped or photographed and are granting full use of the likeness,voice and words without compensation.I have read and understand this waiver and affix my name inagreement.
Parent or Guardian’s Signature
Child(ren)’s Name(s)
Date

MonthDayYear
Date

Payment Agreement
Student(s) Name
Parent/Guardian Name
I understand and agree that I am financially responsible for the payment of all services related in the amount stated below. I agree to pay the full amount in the time period as stated below. I understand that any remaining balance not paid in full will accrue a late fee and that continued non-payment will result in delinquency and the dismissal of the student from all classes as well as the termination of service. For the professional services listed below in dance, fymnastics or cheer, I agree to pay Ms. Patricia’s School of Dance and Gymnastics on a monthly basis, with payment due on the 10th of each month at the tuition. For the duration of this agreement as specified below for Fall or Summer Classes beginning the First Payment and Last Payment Date. I understand that during the term of this agreement, fees for costumes and performances, including but not limited to competition, recital, festivals, and other such scheduled performances will be charged in addition to tuition fees, and that non-payment of these fees will result in the same delinquency as stated below. Payments shall be deemed delinquent if not received by the 20th of each month. If any scheduled payment related to this agreement is deemed delinquent during the term of this agreement, the agreement shall be considered in default, and a late fee of $25 shall be applied to each delinquent payment in addition to any and all accrued dues. At the accrual of three months consecutive delinquency, students will be dismissed from classes and services discontinued until payment is received. Client Signature Date Witness Signature Date
For the duration of this agreement as specified below:
For classes in dance, gymnastics or cheer specified below:
First Payment Date

MonthDayYear
Date
Last Payment Date

MonthDayYear
Date
Rate
Client Signature
Date

MonthDayYear
Date
Witness Signature
Date

MonthDayYear
Date
Should be Empty:

Ms. Patricia's School of Dance & Gymnastics Registration, Photo Waiver, & Liability Agreement

Student Info

Parent/Guardian Info

Tuition Responsible Party

Emergency Contacts

Medical & Liability Release

Photography Waiver

Payment Agreement