Patsy’s Dance Studio
2019 – 2020 Registration Form
Students of dance or gymnastics
Name _______________________________Age _____Birth date __________________
List regular class(es) that ____________(nickname, if any) is registering for:
Day/time/teacher __________________Day/time/teacher ___________________ Day/time
Parent’s name & address: _____________________________________________________________________________
Contact cell No. ______________
Emergency Contact Name & telephone No. ______________________________________________________
PHOTOGRAPHIC RELEASE: I give permission for photos of my child to be taken during dance/tumbling classes.
Photos will be used in social media and advertisements. ____yes ____no
MONTHLY PAYMENTS: I will pay monthly payments and I understand that monthly fees are due on the first class of the each month. If paid after 15th of the month, a $10 late fee will be added to studio account.
RELEASE OF LIABILITY: I, the undersigned, recognizing that classes involving physical activity may result in personal injury, do release Patsy’s Dance Studio & her staff from all liability. In the case of emergency, if I or my emergency contact cannot be reached, I authorize Patsy or her staff to secure medical assistance. I have taken the necessary steps in obtaining accidental, health, or hospitalization insurance that would cover any
Parents are responsible for the safe & timely drop-off & pick up of all students.
Please put name in ALL shoes & articles of clothing.
I HAVE READ, UNDERSTAND AND AGREE WITH ALL THE ABOVE.
Signed by (Parent or legal guardian or adult student)
For office use only
Monthly fee $____________ paid registration day yes____ no ____
Registration fee $20 per family…… yes _____
Amount paid $ ______