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REGISTRATION
FORM
Dee Dots Dance Handbook
Student Name(s)
(Required)
D. O. B
MM slash DD slash YYYY
Mom’s Email
(Required)
Dad’s Email
(Required)
Address
Street Address
City
State
Zip Code
Mom Cell Phone
Dad Cell Phone
Emergency
(Required)
Phone
(Required)
Email
(Required)
Allergies or Medical
Please circle day
Mon.
Tues.
Wed.
Thur
Class Choice
Time
Class Choice
Time
Class Choice
Time
Creation Academy Student
Yes
No
The undersigned parent/student indemnifies and agrees to holds harmless Dee Dots Dance Academy (DDCA), its Board of Directors, officers, instructors, agents, and assigns from any and all liability whatsoever, for any damage or injuries, and from any and all claims and demands, including attorney fees, arising out of the party’s participation in dance lessons, classes, workshops, performances, karate, fundraisers and other related activities provided by and/or at the facility of DDCA. The undersigned parent/student understands that students may occasionally appear in promotional performance videos, photos, brochures, and other materials as a result of his/her association with DDCA. By registering a child/student for class, such use of the child/student’s name and likeness are agreed to and acknowledged and, accordingly, all right, title and interest in same are waived.
Consent
(Required)
I have read and agree to the above terms and conditions of this agreement
(Required)
Consent
(Required)
I have read Dee Dots Dance Academy
Handbook
.
(Required)
Date
MM slash DD slash YYYY
Printed Name
Signature
(Parent's signature if student is under 18)
75810
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