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______________________dgfadsbxbs_______________________ / __________________________________ _______ / _______ / ____________
Student Last Name
Student First NameStudent Birth Date
Student First NameStudent Birth Date________ New Student________Continuing StudentPlease list previous training: _________________________________
________Continuing StudentPlease list previous training: __________________________________________________________________________________________Previous Studio: ___________________________________________
__________________________________________ / _____________________________ PA ________________________
Home Address (Street)Zip Code
Zip CodeHome Phone: ________ / ______ - ___________Cell Phone: ______ / ______ - __________
Cell Phone: ______ / ______ - __________Work Phone: _______ / _______ - __________Other 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 # _______________________________________
Plan # _______________________________________Family Physician: ________________________________________Phone # ______________________________________
Phone # ______________________________________Allergies / Medical Conditions: ____________________________________________________________________________________
I give permission for my child to receive emergency medical care should it become necessary.
__________________________________________________________________________________________
________________________________SignatureDate
DateMedical 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
DateA $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:
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 -acro/ 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, LLC 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.
As myself or the parent or legal guardian of the aforementioned person, I further acknowledge, understand, appreciate and agree that participation may result in possible exposure to and illness from infectious diseases, including, but not limited to MRSA, Influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my participation and exposure.
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 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.
