REGISTRATION FORM
2015-2016 DANCE SEASON

$25 per Family Registration Fee


Section I:                                                         Student                       Date______________

Name:___________________________________________________

Address:____________________________________________City:_______________State:_________Zip________

Phone (______)________________­_ 

Date of Birth:_________­______
 
Email Address__________________________________________

Person to contact in case of emergency_____________________________Phone__________________________

CLASSES OFFERED
BALLET/LYRICAL       TAP JAZZ      HIP-HOP      GYMNASTICS   POINTE      BOYS ONLY      COMBO CLASS

PLEASE NOTE THE CLASSES OF INTEREST AND DAYS PREFERRED.
ALSO, IF YOU WOULD LIKE SAME SCHEDULE AS THIS YEAR, PLEASE INDICATE BELOW.
___________________________________________________________________________________________________________________


Section II                                                         Responsible Party

Name:_______________________________________________ Relationship to Student: ___________________

Address:_____________________________________________________________________________________

City:_________________________________ State:__________ Zip:_____________

Phone: (____)_____________________

 

WAIVER – PLEASE READ AND SIGN BELOW

I hereby agree that neither Dance Revolution with Erika, nor its agents, employees, officers nor directors shall be liable for any injuries,
damages or losses sustained by my child, ________________________ which are in any way related, whether directly or indirectly,
to my child’s participation in all classes, workshops, parties, and special events.
Caution: Any activity involving motion, rotation or height may cause accidental injury.
I also authorize Dance Revolution with Erika to use any photographs or videotape taken of my child for legitimate purposes.


Parent/Guardian Signature_________________________________________Date_________________