Registration Form 2011-2012

Date registered:__________________________

Student’s Name:_______________________________________________

Date of Birth:_____________________  Current Age:________________

Address:______________________________________________________

Home Phone:_______________________  Cell Phone:________________

Work phone:_______________________   email:____________________

Academic school attending:______________________________________

Is there anything specific that we should know about this student?(allergies, ADD, etc.)

_____________________________________________________________

Parent’s Name:________________________________________________

Emergency Contact Name:______________________________________

Relationship:_____________________  Phone:______________________

Best form of contact: ___email  ___home phone  ___cell phone 

(A separate from must be submitted for each child.  Thank you.)

Dance Experience ( please list styles studied and number of years)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Parent Agreement

 I have read and agree to the policies listed in the Dancespace policies.  I agree to abide by all the rules and regulations. I do hereby release all employees, demonstrators, and the owner from any and all claims for damages or injuries which a student or a visitor may have been involved in while participating in activities connected with DanceSpace Inc. 

Parent’s or Guardian’s Signature_____________________________________________

Summer Camp and Classes (please list which class your child will be attending)_____________________________________________________________________________

_______________________________________________________________

*Please print and return to the office