McCartney Irish Dance Registration Form

Classes: Please check all that apply to the specific dancer being registered*

Monday 5:00-6:00 PM Advanced Beginner KidsMonday 6:00-7:15 PM Intermediate KidsMonday 7:15-8:15 Adult Advanced BeginnerTuesday 5:15-6:00 PM Junior Performance TeamTuesday 6:00-7:30 PM Senior Performance TeamTuesday 7:30-8:15 PM Adult BeginnerWednesday 5:00-5:30 Little Steppers Pre-K IrishWednesday 5:30-6:15 PM Beginner KidsWednesday 6:15-7:45 PM Adult Intermediate/AdvancedThursday 6:30-7:30 PM Advanced IrishSunday 2:00-4:00 PM Oireachtas SolosSunday 3:30-5:00 PM Oireachtas Trad SetsSunday 5:00-6:30 PM Oireachtas Ceili Teams

Is the dancer age 18 or older?*

YesNo

Dancer's Name*

First NameLast Name

Nickname

Youth info:

Date of BirthGrade

Mother / Guardian*

First NameLast Name

Father / Guardian*

First NameLast Name

Main Contact Phone Number*

Area CodePhone Number

Secondary Phone Number

Area CodePhone Number

Dancer's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Dancer or Guardians email for communication purposes*

Additional email (if you would like to receive class info and upcoming event notifications on more than one email account)

example@example.com

Email for billing purposes*

example@example.com

Payment schedule*

Monthly (due 1st week of each month)Full amount (1st class to last class at the end of May)Trimester (Sept-Nov, Dec-Feb, Mar-May)

EMERGENCY INFORMATION - If parents/guardians cannot be reached, in case of emergency, notify:

Emergency contact*

First NameLast Name

Relationship to Dancer*

Emergency Phone Number*

DANCER INFO Please fill out the following to help us better serve our students

Special needs and/or things to know that will help us with teaching your dancer

Allergies

Previous dance experience

Interests and goals for this program

How did you hear about McCartney Irish Dance?

I acknowledge and consent to allow McCartney Irish Dance, LLC to take and use photographs, videos or likenesses of myself or my child as needed for advertising, social media and/or public relations projects and that I have no rights to the same and will not be compensated for the same.*

I agree

All persons with legal responsibility for this dancer should sign and date the following:

I understand that it is my responsibility to notify McCartney Irish Dance, LLC of any changes in residence, phone numbers, email and emergency information.

I assume responsibility for the full payment of this dancer's tuition and for the fees and costs of any McCartney Irish Dance, LLC activity to which I have consented. I understand that payment must be timely, and that a $20 late fee is assessed on all past-due accounts. Accounts overdue by 90 days or more may be sent to collections, and the dancer may be denied re-enrollment if payment is delinquent. There is a $30 NSF fee for any returned checks.

I understand that the registration fee and tuition fees are non-refundable.

I understand that no credit is issued for classes missed due to illness or schedule conflicts.

I assume primary and full responsibility for financial obligations to McCartney Irish Dance, LLC incurred by this dancer's enrollment and/or activity participation.

I understand that if for any reason I plan on withdrawing from classes at McCartney Irish Dance, LLC I need to inform the studio via email.

I understand that there is the potential for accidents, personal injury, death, and/or property damage to occur during physical activity. To the fullest extent of the law I knowingly and willingly assume full responsibility for any and all risks associated with this dancer's participation in McCartney Irish Dance, LLC activities and fully release McCartney Irish Dance, LLC and its officers, agents, employees and volunteers from any and all liability or claims arising out of this dancer's participation in McCartney Irish Dance, LLC activities.

I authorize McCartney Irish Dance, LLC to seek medical treatment for this dancer in the event of an emergency, including transportation by ambulance to the nearest hospital. I (we) understand that I (we) am (are) solely responsible for any medical expenses including ambulance transportation, which this dancer may incur from any injuries.

I hereby certify that I have read the above and agree to abide by all *

Enter your full name

Relationship to the dancer*

Signature*

Date*

Date

Signature*