PILATES and CONDITIONING - 8 Week Session FALL

OCT 17 - DEC 5, 2016
Monday Evenings - 8:15-9:15 pm

8 Week Session - $125

Student's Name Student's Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Parents/Guardians
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone (Mother) Home Phone (Mother) - ### - ### ####
Home Phone (Father) Home Phone (Father) - ### - ### ####
Bus/Cell Phone (Mother) Bus/Cell Phone (Mother) - ### - ### ####
Bus/Cell Phone (Father) Bus/Cell Phone (Father) - ### - ### ####
School
How You Heard About Us
Medical Information
Emergency Contact

Person to contact in case parent or guardian is unavailable
Name Name First Last
Relationship
Phone Phone - ### - ### ####
Release
I grant permission to the staff of the dance school to take first aid or emergency measures as judged necessary for the care and protection of my child or myself as a parent participating in an organized school activity while under the supervision of the school. In case of medical emergency, I understand that my child/myself will be transported to an appropriate medical facility by the local emergency unit for treatment if the emergency unit deems it necessary. I understand that in some medical situations the staff will need to contact the emergency resource before the child’s parent, physician, and or other person acting on the parent’s behalf. I also understand and agree that the child’s parents or legal guardians shall be responsible for any expenses incurred. As the parent/legal guardian of
I agree to hold harmless from any and all liability the school, its officers, employees, independent contractors, both in their professional capacity and personally, for all injury or illness resulting from or in any way connected with his/her participation and parents and siblings participation in the classes, activities or special events at the school. I understand that it is the school’s policy that while under the supervision of the school no child is allowed to leave the building without a parent/legal guardian or the written permission of a parent/legal guardian and that the parents/legal guardians assume full responsibility for the actions and behavior of the child, the child's siblings and themselves. Parents/legal guardians give their permission to the school to use photos and or video of their child, child's siblings and themselves without remuneration in connection with school publications, advertising, news and tv coverage. Registration is for the full dance season, September to June. Tuition is based on the full season and all payments are nonrefundable. Costumes can not be cancelled or returned for a refund, ALL Costume Payments are nonrefundable.

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Full Name

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Date Date / MM / DD YYYY
Your Email Address
After Submission
This form will direct you to Paypal for SESSION payment. You do not need to have a Paypal account to pay via credit card at Paypal. Thank you.

PILATES and CONDITIONING - 8 Week Session FALL

PILATES and CONDITIONING - 8 Week Session FALL

Emergency Contact

Release