Today's Date *

MM

DD

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Student's Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Student's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student's Phone Number (Home) *

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Student's Phone Number (Cell) *

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Parent's Name/Legal Guardian *

First Name

Last Name

Parent/Guardian's Phone Number (Work) *

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Parent/Guardian's Phone Number (Cell) *

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Parent's Name/Legal Guardian *

First Name

Last Name

Parent/Guardian's Phone Number (Work) *

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Parent/Guardian's Phone Number (Cell) *

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I understand that I am responsible for class fees and all late charges/returned check fees if so accrued. I understand that there are no refunds nor credits given for missed classes or voluntary withdrawal. I have read and understand the studio guidelines. *

Consent: Dance Express LLC takes photos, videos, and/or films throughout the year in our studio/classes. We may use such materials for promotional purposes. I understand that I may be in photos, videos, and/or film used by Dance Express LLC. *

Release: I recognize the inherent risks of accident and injury associated with any program of dance and/or exercise and acknowledge that I or my child(ren) am/are participating upon the express understanding that I am willing and able to accept full responsibility for my own or my children’s own safety and welfare. I hereby release Dance Express LLC, Jennifer Weigand-Watkinson, and the property owners and agree to hold Dance Express LLC, Jennifer Weigand-Watkinson, and the property owners harmless from and against any and all claims and liabilities whatsoever which I may have arising out of my or my child(ren) participation at Dance Express LLC. I release Dance Express LLC, Jennifer Weigand-Watkinson, and the property owners from and against all claims and liabilities of my person or my child(ren)’s person and my or my child(ren)’s personal property while attending classes at Dance Express LLC. I hereby execute and deliver this release to induce Dance Express LLC, Jennifer Weigand-Watkinson, and the property owners to permit me to participate in its programs.

Emergency Contact *

First Name

Last Name

Home Phone *

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Work/Cell Phone *

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