ACADEMY OF DANCE- CIRCLE: SUMMER
FALL 2010-11
Summer
Classes________________________________________________________________
Fall
Classes____________________________________________________________________
Students
Name_________________________________________________________________
D.O.B_______________
Age________ Home phone_______________ Cell________________
Address___________________________________________________
Zip Code____________
Email(Must Have)______________________________________________________________
Parents
Names__________________________________________________________________
Mother’s
employment________________________________ Work Phone_________________
Father’s employment__________________________________Work
Phone________________
School Or
Day Care______________________________ Medical Conditions_______________
Photo Clause: We use class and
performance photos for advertising and promotions. Initial if you do not want
your photo used____________
I, the undersigned, do hereby
release Academy of Dance, L.L.C. and its staff and Instructors from and all
claims of liability in the event of injury
concerning myself (adult students) or my child while
participating in a dance class and/or any dance related activity and/or
performance on
premise or on location . I have read and understand the
information guide.
Parents
Signature_________________________________________ Date__________________
Card
#__________________________________________________ Exp.__________________