January 18th - April 2016 Registration Form

Today's Date*

MonthDayYear

Student Name*

First NameLast Name

Sibling (Student 2) Name

Parent's Primary Email*

Parent's Secondary Email*

How did you hear about us?*

Student's Birthday*

MonthDayYear

Make your class selections:*

Monday 4:45 - 5:30 Hip Hop I (Beginner) Ages 8-12

Student's Age*

Student's School*

Guardian Name & Relation*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Emergency Contact Name, Relation, Cell #*

Does the dancer have any medical problems that we should be aware of? If yes, please explain.*

By checking this box, I hereby release Downtown Dance employees/independent contractors, from all libability from personal injury, illness or property damage occuring on or off the sudio's premises. I have read Downtown Dance's Policies & Information. I authorize Downtown Dance to discharge my child to an ambulance with the nearest medical facility, should there be a medical emergency. I certify that my student is in good health and capable of participating in physcial activities. I hereby give permission to Downtown Dance to take and use photos and videos for the promotional uses of the studio. This includes, but is not limited to, the studio's facebook page and Youtube channel where students names are not disclosed. Lastly, I understand that tuition is not refundable.

I agree

Electronic Signature / Date*

Payment

Registration Fee$15.00

Total $0.00

With Sign-Up Recieve a Free T-Shirt!

** Please note that the tuition fee of $131 dollars will be due the week of January 25th. **

Downtown Dance Jan 18 - April 11, 2016 Registration Form *No class March 14