Registration & Parental Release Form

"A Dancer's Dream"

Registration & Parental Release Form

Billing Name ______________________________________________________

Address ______________________________________________________

City _________________________State_________Zip________________

Email address ________________________________________(important statements are now emailed) Please print

Home Phone______________________

Work Phone_____________________

Parent 1 Name ______________________________

Cell _________________

Parent 2 Name ______________________________

Cell _________________

Student Name _______________________________

Grade _______________

Birthdate ___________________________________

Age_________________

School_____________________________________

Any Physical or Medical Conditions that we need to be aware of:

Please list.

________________________________________________________________

TUITION IS DUE THE FIRST (1st) MONDAY OF EACH MONTH. September to May.

Note: Pay the full year tuition(September - May) before September 30th and receive a 5% discount. (Cash or Check only)

Please fill out requested classes dates and times below.

Class Name

Day/Time

Tuition

Sub Total ________________

Registration Fee $20________________

Total Due ________________

Please Make Checks Payable to Seaside Dance Academy

Parental Release Agreement

I certify that my child_____________________________________has no physical disabilities or conditions that could limit her/his full and active participation in the Seaside Dance Academy dance program. I understand that any activity involving motion or rotation of the body is potentially hazardous, and hereby accept this risk.

Seaside Dance Academy does not carry medical insurance for its students. It is required that all dance students be covered by their own family insurance policies, and if injury occurs, it it understood that the student's own policy is your only source of reimbursment.

Parent or Guardian signature________________________ Date_______________