Jazz Tap Combo Dance Class Registration Signup Form

Jazz Tap Combo Dance Class Registration Form

Fridays, starting January 3, join us for a jazz/tap combo dance class with Jessica Umbleby!
Parent/Guardian Name

First Name Last Name
Student Name *

First Name Last Name
Birth Date

Month Day Year
Gender
Parent E-mail *
example@example.com
Mobile Number *

Area Code Phone Number
Phone Number

Area Code Phone Number
In case of emergency, please notify (include name and telephone number):
Emergency Contact (Name and Phone)
Please list any physical limitations, special needs, or allergies:
I'd like to pay online:

Yes No, I'll pay in person by check No, I'll pay in person by cash

Class is $195 and must be paid in full by January 1

Child/Beginner (ages 6-11) 6:30-8:30pm Fridays $ 195.00

Subtotal $ 0.00 Tax $ 0.00 Shipping $ 0.00 Total $ 0.00

Additional Comments
I understand that these classes require physical activity and that injury may occur. I agree not to hold responsible Star Performance Academy, Be3, Airfast Heating & Cooling, Inc., Airfast Home Improvement, Inc., Directors, Instructors, Staff, or Board Members. A written consent is required if someone other than the parent or guardian is to pick up or transport the child. Parents must arrive within fifteen minutes after the end of a scheduled class or rehearsal to pick up child. Due to limited enrollment, I understand that I am committing my child (or myself) for the entire summer camp, class, or rehearsal session: *

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Jazz Tap Combo Dance Class Registration Form