STARR'S STUDIO OF DANCE

Student’s Name (First & Last): ________________________________ Date of Birth (if under 18):_____________
Mailing Address:___________________________________________________________
City/Town: State: Zip:_______________________________________________________
Home Telephone #: ________________________________________________________________________

Mother’s Name: ___________________________________ Mother Cell #:___________________________
Father’s Name: __________________________________________ Father Cell #:____________________________
 

Name of Responsible Party: _____________________________________________________________________________
If address and phone numbers are different from above please include: Telephone #: _______________________
Street: ______________________________________ City: ____________ State: ________ Zip: _____________

Would you prefer to receive dated communications from us via email? ______Yes _____No
If yes, please provide proper email address: ____________________________________________________________________

Please advise us of any medical conditions that may affect the student’s participation:
_____________________________________________________________________________

Agreement for Participation
I understand that dance classes may include, without limitation, dancing with props, stretching, barre work, across the floor combinations, dance routines in the center, and other related activities. I further understand that all of the activities of the dance class involve some degree of risk of strain or bodily injury.
Starr's Studio of Dance is not responsible for personal property.

I have received the student handbook and agree to adhere to all the content stated therein including:

*Studio Policies *Tuition & Payment Information *Calendar

I agree to be responsible for reading studio correspondence and respecting deadlines, if applicable.
I hereby acknowledge that I have read the statements above and agree to participate accordingly.

Date: __________________________________ Signature: _______________________________________________________

Please list the class(es) you wish to enroll in.

Style & Level, Age Group, Day/Time/Teacher, Tuition Due

1.            $
2.            $
3.            $

Registration Fee:_____$25.00_______________
 

SUB-TOTAL: $

TOTAL: ­­­­­­­­$

Balance Due: ­­­­­­­­$



For Office Use Only:

# ______ AB _____ QBA _____QBR _____QBM _____DBA _____DBC _____EM _____LB



Starr's Studio of Dance
10 Landmark Lane
Kent, CT 06757


Liability Waiver
1. I am participating in dance class offered by Starr Jeffreys, Amie Bush, Briana Juliano, or Starr's Studio of Dance, LLC. during which I will receive information and instruction about dance. I recognize that dance requires physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the dance classes. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in dance classes.

3. In consideration of being permitted to participate in dance class, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which might incur as a result of participating in the program.

4. In further consideration of being permitted to participate in dance class, I knowingly, voluntarily and expressly waive any claim I may have against Starr Jeffreys, Amie Bush, Briana Juliano, or Starr's Studio of Dance, LLC. for injury or damages that I may sustain as a result of participating in the program.

I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Starr Jeffreys, Amie Bush, Briana Juliano, or Starr's Studio of Dance, LLC. for any injury or death caused by their negligence or other acts at the studio, or at a event with Starr's Studio of Dance and their teachers. Such as recital or competitions.

I have read the above Release and Waiver of Liability and fully understand it’s contents. I voluntarily agree to the terms and conditions stated above.

__________________________________________________________________________

Name, Date


PARENT/LEGAL GURDIAN (if student is under 18 years of age): I have read the above WARNING and I understand that this class may potentially involve the RISK OF INJURY and that by permitting my child/ward to participate in this class they may be subject to the possibility of injury. I acknowledge that I do understand the contents of this form and I voluntarily choose to permit my child/ward to participate and by my signature do hereby release, indemnify and hold the studio, its owner, employees and agents harmless from any claims, damages, demands, liabilities and costs incurred including attorneys fees. I understand and acknowledge that I have been encouraged to seek legal counsel before signing this document and that by signing this form

I am severely limiting my legal rights. A complete copy of this form will be provided to me upon request.

_______________________________________________________________________

(Parent/Guardian's Signature) Date