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Center Stage Dance Interim Session Enrollment
Please fill out 1 form for each dancer you are registering.
Please DO NOT fill out if you are looking for general information. Instead contact us directly at:
centerstagedanceteams@gmail.com
Dancer Name:
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Birth Date
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14-15 School Year Grade
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k3
K4
K5
1st
2nd
3rd
4th
5th
6th
7th
Parent/Guardian Name:
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Address 1
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City
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Zip
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Phone
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Alternate Phone
Email Address:
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What class(es) are you enrolling in?
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Boyz Only Hip Hop (Ages 8 +)- 3 week trial class ($15)
Boys Only Hip Hop (Ages 5-7)- 3 week trial class $15
I have been given staff permission to enroll in advanced tumbling?
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Yes
No
Please click if you are enrolling more than one dancer from your family.
Family Discount
Any coupon code (if you have one):
Current Total:
$0.00
Calculate
Emergency/Medical Information
Please List 2 Emergency Contacts Below:
Contact Name:
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Relationship:
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Phone Number:
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Contact Name:
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Relationship:
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Phone Number:
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Insurance Company:
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Policy Number:
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Family Doctor Name:
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List pertinent medical information applicable to: allergies, nervous disorders, heart trouble, diabetes, epilepsy, etc.
Indicate any medication or drugs to which the participant if allergic
Indicate any medication the participant is currently taking
The risk of injury to myself from the activities involved in these programs is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 1) FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and, 2) I willingly agree to comply with the program's stated and customary terms and conditions for participation. If I observe any unusual significant concern in my child's readiness for participation and/or in the program itself, I will remove my child from the participation and bring such attention of the nearest official immediately; and, 3) I myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Center Stage Dance, LLC its directors, officers, officials, agents, employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to my child's involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. 4) I, for myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. 5) I understand the seriousness of the risks involved in participating in this program, my personal responsibilities for adhering to rules and regulation, and accept them as a participant. 6) I authorize a representative of the Center Stage Staff to locate qualified and licensed medical personnel and/or transport said student to an appropriate medical facility in the event that it may become necessary. I understand I will be notified as soon as possible in the event of an emergency. I or my insurance company will assume all expenses of such treatment.
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I have read above and agree
Photos and video clips will be taken during the year and may be used in marketing materials for Center Stage Dance. I give permission to Center Stage Danceto use the above mentioned still, or moving images in any medium for educational, promotional, advertising, or other purposes.
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I have read above and agree
Print Name:
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Sign Below:
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clear
Please hit continue button below to complete your registeration. You will be redirected to paypal for payment. Students are not considered registered until payment is recieved.
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