Loveland Dance Academy: Registration Form

lda Registration Form

Classes:

1._____________________________________Day__________________Time____________

2._____________________________________Day__________________Time____________

3._____________________________________Day__________________Time____________

4._____________________________________Day__________________Time____________

Dancer’s Name __________________________________________________ Date_______________

Address___________________________________City________________________Zip___________

Phone________________________email_______________________________________Age_______

Birthday_______________Grade________________________School___________________________

Mother’s Name _______________________Address (if different) _____________________________

Mother’s home phone________________cell__________________email_______________________

Father’s Name_______________________ Address (if different) _____________________________

Father’s home phone _________________ Address (if different) _____________________________

Person to contact in case of emergency (other than above):

Name_________________________________ Phone (h)_________________(w)________________

Medical release form ( to be completed by every student and instructor):

I, _____________(student) release the Loveland Dance Academy, their agents, employees successors and assigns, from any and all liability, claims and causes of action by me or my heirs, successors and assigns arising out of or any way related to my participation in or presence at classes, recitals, performances or other events in relation with Loveland Dance Academy. I hereby state that I am physically fit to participate in dance classes for the level of class I participate in this year or in the future. I am fully aware of the risks or injuries associated with or related to participation in dance classes or performances and I assume all responsibility and such risks in consideration of being allowed to register for classes.

Signature of student (if over 18 years of age) _____________________________________Date______________________

Signature of parent (if under 18 years of age) _____________________________________Date______________________

Photography and/or World Wide Web permission:

I_____________________________(student) understand that professional photographers and videographers are employed by the Loveland Dance Academy for performances, recitals and promotionals (including World Wide Web documents)

I hereby give consent to allow photographing for the sole purposes of the Loveland Dance Academy only

_________________________________________________Date ____________________

I do not give consent to allow photographing for the sole purposes of the Loveland Dance Academy only.

_________________________________________________Date___________________