Dance Registration Form

Dance Registration Form

(Please Circle)

I am registering for: Fall Dance / Summer Dance

Please Print

Student Name______Date of Birth______

School______Grade______Age______

Home Address______Male/Female______

City______State______Zip Code______

Home Phone______Student Cell Phone

Student email

Parent/Guardian Name______

Work Phone______Cell Phone______

Email address(Very Important!)______

Parent/Guardian Name______

Work Phone______Cell Phone______

Email address(Very Important!)______

Web site Please check regularly!)

(New Students)Please List Previous DanceSchools and Years of Experience in Each Style of Dance

Dance Schools:______

Tap______Jazz______Ballet______Pointe______HipHop______Other______

Notes:

Waiver and Release

I recognize the risks of illness and injury inherent in any exercise, dance, music, art or theater program. This student is participating upon the express agreement and understanding that I am hereby waiving and releasing the e-dance center, its owners, employees and contractees from and against any and all claims, costs, liabilities, expenses or judgments, including attorney’s fees and court costs arising out of participation in this program or any illness or injury resulting there from , and hereby agree to indemnify and hold harmless the e-dance center, its owners, employees and contractors from any and all such claims.

We Fully understand and voluntarily accept that:

1. It shall be the parent/guardians sole discretion to grant permission to the student for the ability to leave the premises of the e-dance center for the situation such as, but not limited to, walking home, waiting to be picked up, going out with friends, etc. The e-dance center will not monitor or enforce this ability or be held liable or a student leaving the premises before, during, or after classes or any other functions held by the e-dance center.
2. There may be other dangers and risks from said participation in any and all activities not known to us or not foreseeable at this time.

Photo/Media Release:

I hereby grant the e-dance center the right to use the name and image of the undersigned to all forms and in all media and in all manners, for the purposes of marketing, advertising, show video, show decoration, or other lawful purposes.

I UNDERSTAND I AM ASSUMING ALL RISKS INHERENT WITH ANY AND ALL ACTIVITIES THAT I AM PARTICIPATING IN. WHETHER KNOWN OR UNKNOWN, AND THAT BY SIGNING THIS DOCUMENT I AM GIVING UP MY RIGHT TO SUE THE E-DANCECENTER WHETHER CAUSED BY THE NEGLIGENCE OF SAID PERSONS OR ENTITIES.

I VOLUNTARILY SIGN MY NAME EVIDENCING MY ACCEPTANCE OF THE ABOVE PROVISIONS, AND FURTHER AGREE THAT NO ORAL REPRESENTATION, STATEMENTS OR INDUCEMENTS APART FROM THE AGREEMENT HAVE BEEN MADE.

I HAVE READ THE DOCUMENT. I UNDERSTAND IT IS A RELEASE OF ALL CLAIMS.

______(Student)______(Date)

______(Parent/Guardian)______(Date)

(Signature required if student is a minor)

Thank you for choosing e-dance center! We will contact you soon!

399 North Hanover Street

Elizabethtown, Pa17022

(717) 689-5295