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______________________dgfadsbxbs_______________________ / __________________________________ _______ / _______ / ____________
Student Last NameStudent First NameStudent Birth Date

________ New Student________Continuing StudentPlease list previous training: _________________________________

_________________________________________________________Previous Studio: ___________________________________________


__________________________________________ / _____________________________ PA ________________________
Home Address (Street)Zip Code


Home Phone: ________ / ______ - ___________Cell Phone: ______ / ______ - __________

Work Phone: _______ / _______ - __________Other Phone: _______ / _______ - _______  


E-Mail Address: ________________________________ @ _____________________
  Please print clearly (Most communication is done via e-mail)

Contact person in the event parents cannot be reached: _____________________________________Phone: _______/ _______ - _________


Medical Information: Please read the following carefully. Your child will not be permitted to attend classes until all release information has
been completed, signed & received in the office.

I am fully aware that Dance & dance-related / gymnastics / exercise / stretching associated with it can place an unusual strain on the body
& carries with it the risk of physical injury. On behalf of my child, Dancers Edge By Rogers, Inc. and the teaching staff shall not be held
liable in any way for injuries sustained or loss of property during attendance at the school or its related functions. I also understand that
any property damage caused by unsupervised children will be the responsibility of the parent.


Medical Insurance: _______________________________________Plan # _______________________________________

Family Physician: ________________________________________Phone # ______________________________________

Allergies / Medical Conditions: ____________________________________________________________________________________


I give permission for my child to receive emergency medical care should it become necessary.

__________________________________________________________________________________________
SignatureDate

Medical Release: I give permission for photographs / video footage which includes my child to be used for professional purposes on 
television, newspapers, web site or any other form of media.

_________________________________________________________________________________________
Parent / Legal GuardianDate

A $20.00 NON-REFUNDABLE registration / processing fee is required to enroll one child, $35.00 for two, $50.00 for three or more

Office Use only:Registration Fee Received _____ Studio Policies ______Method used to locate studio: 
Advertisement ______Referral __________



















Medical Information: Please read the following carefully. Your child will not be permitted to attend classes until all release information has been completed, signed & received in the office.


I am fully aware that dance & dance-related / gymnastics / exercise / stretching associated with it can place an unusual strain on the body & carries with it the risk of physical injury. On behalf of my child, Dancers Edge By Rogers, Inc. and the teaching staff shall not be held liable in any way for injuries sustained or loss of property during attendance at the school or its related functions. I also understand that any property damage caused by unsupervised children will be the responsibility of the parent.



​  I give permission for my child to receive emergency medical care should it become necessary.

​ By submitting this form I give permission for my child to receive emergency medical care should it become necessary.

 A $20.00 NON-REFUNDABLE registration / processing fee is required to enroll one child, $35.00 for two, $50.00 for three or more.

CHECKS ARE DUE WITHIN 7 DAYS OF REGISTRATION TO HOLD YOUR SPOT IN THE CLASS




Except as disclosed in this Privacy Statement, we do not sell, trade, rent, or otherwise retransmit any Personally Identifiable Information we collect online unless we have your permission. Any Personally Identifiable Information you provide to us will be used for your purchases and retained in hard copy form of the original invoice as well as within our database system, which generates our invoices. 

From time to time, we may be required to provide Personally Identifiable Information in response to court order, subpoena, or government investigation. We also reserve the right to report to law enforcement agencies any activities that we in good faith believe to be unlawful. We may release Personally Identifiable Information when we believe that such release is reasonably necessary to enforce or apply our Limited Warranty or to protect the rights, property, and safety of others and ourselves. 

Student Last Name:
Student First Name:
Student Date of Birth:
Home Address (Number & Street):
City:
State & Zip Code:
Home
About Us 
Faculty
Company
REC Schedule
Photos
Achievements
Contact Us 
Register 
In-Class Videos
Competition Videos

Home Phone:
Work Phone:
Cell Phone:
E-Mail:
Alternate Contact if parent cannot be reached:
Phone:
Plan #:
Phone:
Date:
Parent/Legal Guardian:
How Did You Hear About Us:
​Family Physician:

Medical Insurance:
Allergies / Medical Conditions:
ONLINE REGISTRATION FORM

Class Day & Time Registering : 
Time:
I give permission for my child to be in any video footage, and photographs which may be used for
professional purposes on television, newspapers, internet, or any other forms of media. 
Permission Granted
Permission Granted