Nrityam School of Dance - Student Enrollment & Waiver Form

Nrityam School of Dance - Student Enrollment & Waiver Form

Please complete every applicable section. If the student is under 18 years of age, a parent or legal guardian must complete the Parent/Guardian Information section and must sign on the student's behalf.
Student Information
Student Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Current Age
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Student Phone
Please enter a valid phone number.Format: (000) 000-0000.
Student Email
example@example.com
Preferred Name / Nickname
Gender
Parent/Guardian Information
Required for all students under the age of 18. This person is the primary contact and authorized signer.
Parent/Guardian 1 Full Name

First NameMiddle NameLast Name
Relationship to Student
Home Address (if different from student)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Parent/Guardian 2 Full Name (if applicable)

First NameMiddle NameLast Name
Relationship to Student
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Emergency Contact
Complete only if different from the parent/guardian listed in Section 2.
Full Name

First NameMiddle NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Class & Program Selection
Class Level
Class Type
Trial Class Request
Prior Dance Training / Experience
Preferred Class Day(s) / Time(s) (Optional)
How did you hear about Nrityam School of Dance?
Health & Medical Information
Please list any medical conditions, allergies, injuries, or physical limitations the instructors should be aware of
Physician Name
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Health Insurance Provider
Policy Number
Authorization for basic first aid and emergency medical care
Photo, Video & Media Release
From time to time, Nrityam School of Dance photographs and records students during classes, rehearsals, and recitals for use in studio records, the studio website, social media, promotional materials, and recital videos or programs.
Photo/Video Consent
Assumption of Risk, Waiver of Liability & Release
Dance instruction involves physical activity and inherently carries a risk of injury, including but not limited to muscle strains, sprains, falls, and collisions with other students or studio equipment. I understand and voluntarily assume all risks associated with my child's (or, if an adult student, my own) participation in classes, rehearsals, performances, and related activities at Nrityam School of Dance (the Studio).

In consideration of being permitted to participate in Studio programs, I, on behalf of myself, my child, and our heirs and personal representatives, release, waive, discharge, and covenant not to sue the Studio, its owner, instructors, employees, and agents (collectively, the Released Parties) from any and all liability, claims, demands, or causes of action arising out of or related to any loss, damage, illness, or injury sustained while participating in Studio activities, except to the extent caused by the Released Parties' gross negligence or willful misconduct.

I further agree to indemnify and hold harmless the Released Parties from any loss, liability, damage, or cost they may incur arising out of my child's (or my own) participation in Studio activities. This Waiver and Release is intended to be as broad and inclusive as permitted under the laws of the State of Kansas; if any portion is held invalid, the remainder shall continue in full force and effect.
Studio Policies Acknowledgment
By signing below, I acknowledge and agree to the following studio policies:

• Tuition is due by the 5th day of the first month of each quarter; a late fee of $25 applies after the 5th.

• Fees can be paid by Cash, Check (payable to Ketaki Ghanekar), or Zelle (913-333-7570).

• No refunds or credits are issued for missed classes; make-up classes may be scheduled with instructor approval, subject to availability.

• A minimum of 30 days' notice is required to withdraw from classes.

• Students should arrive 5 minutes before class time, dressed in appropriate dance attire with hair secured away from the face; no jewelry should be worn during class.

• Students and parents are expected to treat instructors, staff, and fellow students with courtesy and respect at all times.

• The Studio reserves the right to dismiss any student whose conduct is disruptive or unsafe.
Signatures
I have read, understood, and agree to all terms, conditions, and waivers contained in this form.
Are you signing as:
Student Signature
Date

MonthDayYear
Date
Should be Empty:

Nrityam School of Dance - Student Enrollment & Waiver Form

Student Information

Parent/Guardian Information

Emergency Contact

Class & Program Selection

Health & Medical Information

Photo, Video & Media Release

Assumption of Risk, Waiver of Liability & Release

Studio Policies Acknowledgment

Signatures