Print This Form And Bring To Class
Student’s Last Name ___________________________ First Name ____________________
Street Address ______________________________________________________________
City __________ Zip ________ Home ph ______________ Work Phone _______________
Parent’s Email ________________________ Student’s Email ________________________
Birth date ___________ Age ____ Grade ____ Emergency # _________________________
Parent/Legal Guardian ________________________________________________________
Has your child had previous dance training? _____ Describe __________________________
Explain if your child has any physical, mental or emotion disorders ____________________
_____________________________ Special medications? ___________________________
How did you hear about us? __________________________________________________
* Payments are non-refundable
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Total Class Tuition __________________
Registration Fee $30.00
Total_________________
Check # ______________
Parent Signature____________________________________________ Date ______________
3305 N. Elizabeth Suite B Pueblo, CO 81008
Website: www.wheredanceisfun.com
Email: wildfirebellydanceco@yahoo.com
I have enrolled _____________________________________________, in a program of strenuous physical activity, offered by Lori's Studio of Dance and Performing Arts (LSPDA). I hereby affirm that I am or the above named person (s) are in good physical condition and do not suffer from any disability that would prevent participation in this dance program. In consideration of myself, or the above named person (s) participation in this program, I, for myself, my heirs and assigns, hereby release the Lori's School of Dance and Performing Arts the owner/director, Lori Trejo, her family, or employees from any claims, demands and causes of action arising from my or the above named person (s) participation in any of the above stated programs, and I hereby release Lori's Studio of Dance and Performing Arts, the owner/director, Lori Trejo, her family or employees, from any liability now or in the future including but not limited to heart attacks, muscle strain, pulls, tears, broken bones, shin splints, heat prostration, knee or lower back or foot injuries and any other illness, soreness or injury, however caused, occurring before, during, or after participation in any of the above stated programs offered at Lori's Studio of Dance and Performing Arts, or at any time, while in the vicinity of the premises of the above stated business, or in any activity sponsored, represented or organized by Lori's Studio of Dance and Performing Arts, the owners/directors, Lori Trejo, her family, or employees, for any reason.
By signing, I hereby affirm that I have read and fully understand & agree with the above waiver.
I also understand that by signing below, I a fee to pay monthly tuition based on classes taken, due by the first day of the month and that a late fee of $10.00 will occur if not paid by the 5
th of the month, whether or not the above student (s) attends classes. There will be no credits for missed classes.Signature of Parent/Guardian __________________________________Date ____________