Samskriti Registration Form 2024-25

Online Registration for 2024-25 Academic Year (Dance - Bharatanatyam/Kuchipudi)

www.samskriti.com
All students (new/returning/group/private) are required to register annually at the beginning of the academic year. ONLY one registration is required per family. If there is more than one student from your family, please list all the names on this form itself.

Step 1: Before registering, please read the important guidelines on our website registration page: https://www.samskriti.com/registration.html

Step 2: Submit this registration form. You do not have to print this form.

Step 3: This year, we will be using autopay for the monthly tuition payment. Please complete the ACH authorization form so that we can set up the tuition payment.

Please note: For direct deposit, you will not be charged a processing fee. For credit card payment, there will be a processing fee of upto 5% per transaction.

Please complete your annual registration before your first class.

If you have any questions, please do not hesitate to contact me by phone: 630.527.1498 or email: samskriti@aol.com

Section 1: Student Information (ALL STUDENTS)
Student #1 Full Name*

First NameLast Name
Student # 2 (sibling) Full Name

First NameLast Name
Student # 3 (sibling) Full Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Registering for (check all that apply)*

BharatanatyamKuchipudi
Are you a*

New studentReturning student
Student*

ChildAdult
Student #1 Date of birth*

MonthDayYear
Student #2 (sibling) Date of birth

MonthDayYear

Section 2: Contact information (ALL STUDENTS)
Father's Name *

First NameLast Name
Mother's Name*

First NameLast Name
Father's Cellphone Number*

Area CodePhone Number
Mother's Cellphone Number*

Area CodePhone Number
Preferred cellphone for Remind communication*

FatherMotherBoth
Home phone *

Area CodePhone Number
Father's email*
example@example.com
Mother's email*
example@example.com

Section 3: Details of previous training (only NEW or TRANSFER students need to complete this section)
Please list name/s of previous teachers and number of years that you have trained
Provide details of adavus and/or items learnt

Section 4: Liability waiver (ALL STUDENTS)
Liability Waiver*

"I understand that there are risks of physical injury associated with, arising out of and inherent to the activity of dance & yoga. In recognition of this acknowledged risk of injury, I knowingly and voluntarily waive all right and/or causes of action of any kind, including any and all claims of negligence arising as a result of such activity from which liability could accrue to Samskriti Foundation and/or Samskriti Academy, its officers, agents, employees, instructors, subsidiaries, parent corporations, and all affiliated entities (hereinafter collectively referred to as “Samskriti Foundation and/or Samskriti Academy”). I hereby agree to release Samskriti Foundation and/or Samskriti Academy and hold Samskriti Foundation and/or Samskriti Academy harmless of all liability, and hereby acknowledge that I knowingly and voluntarily assume full responsibility for all risks of physical injury arising out of active participation in dance on behalf of the participant. I am aware that this is a release of liability and an acknowledgement of my voluntary and knowing assumption of the risk of injury. I have signed this document voluntarily and of my own free will in exchange for the privilege of participation. If I am a minor, my parent and/or legal guardian has signed this document releasing Samskriti Foundation and/or Samskriti Academy from any and all such liability described above and has acknowledged that I am knowingly and voluntarily assuming all risks of injury inherent to this activity.""My child has my full permission to participate in all Samskriti Foundation and/or Samskriti Academy events. I further release Samskriti Foundation and/or Samskriti Academy of all liabilities associated with my child’s participation in any of Samskriti Foundation's dance/music performances, either organized by Samskriti Foundation or by any other community or cultural organization."
Does the student have any physical/medical restrictions or food allergies that we should be aware of?*

SECTION 5: Photo/Video release (ALL STUDENTS)
Photo/Video Release*

"I acknowledge that Samskriti Foundation and/or Samskriti Academy may choose to use my child's photo or video at this time, or may do so at its own discretion at a later date. I authorize Samskriti Foundation and/or Samskriti Academy, its assigns and transferees to copyright, use and publish the same in print and/or electronically. Samskriti Foundation and/or Samskriti Academy reserves the right to discontinue use of photos or video without notice. I have read this release and I understand its contents. I consent to and authorize the use by Samskriti Foundation and/or Samskriti Academy, or anyone authorized by Samskriti Foundation and/or Samskriti Academy, of any and all photographs or video which have been taken of my minor child/children." [Students of Samskriti Foundation/Samskriti Academy may have the opportunity to be photographed or videotaped at various dance/music events that are organized by Samskriti Foundation and/or various community organizations. These photos or videos may be included in Samskriti Foundation and/or Samskriti Academy publications or advertisements, including on our websites, social media, print materials, and other marketing materials. To ensure privacy, names of minor children will not be included. No financial compensation shall be given for use of any photographs or video]

SECTION 6: Please acknowledge (ALL STUDENTS)
Acknowledgement*

We have read and understood Samskriti Foundation's policies and guidelines. We whole-heartedly agree to follow ALL the policies and guidelines. We will fully support the ideals of Samskriti Foundation/Academy and actively participate in all its programs/events.
Signature*

Clear
Date of registration

MonthDayYear

Annual Registration*

Annual Registration $36.50

Registration $35; Handling fee $1.50

Total $0.00

Credit Card

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Online Registration for 2024-25 Academic Year (Dance - Bharatanatyam/Kuchipudi)

Credit Card