Dee Dots Dance Academy

                                 Fall Registration 2019-20

                                                                  856-467-8998

                                    deedotsdance@comcast.net

                                                     Registration Fee $25.00                                                                                       Type into form fields/ print out page.                                      

 

Student Name(s):___________________________________________________
 

Address:___________________________________________________________

City:__________________________   State: _____   Zip Code: _______________

 

Parents Name(s): ____________________________________________________
 

Phone No 1: ________________________       2:  _______________________________
 

Work Phone: _______________________
 

Cell Phone: _________________________
 

Emergency Contact: ______________________________Phone: _______________
 

Date Of Birth:      ____/ _____/______
 

Email: _____________________________
 

Allergies/Medical: ____________________________________________________
 

Please circle day:                Mon.                        Tues.                      Wed.                       Thur.
 

Creation Academy Student:      Yes                  No
 

Class Choice   1 :  _____________________________ Time:  _______________________

Class Choice   2:   ______________________    ______Time : _______________________

 

Class Choice 3:   __________________________Time : ______________________
 

                     
              Return to:                  Dee Dots Dance Academy

                                                  360 Garwin Rd. ,
                                              Woolwich, N. J. 08085  


                               Please read, sign and return with registration  

                                           Hold Harmless Agreement/Release Waiver

                                                         ( Required  by Insurance Co.)
The undersigned parent/student indemnifies and agrees to holds harmless Dee Dots Dance Academy (DDCA), its Board of Directors, officers, instructors, agents, and assigns from any and all liability whatsoever, for any damage or injuries, and from any and all claims and demands, including attorney fees, arising out of the party’s participation in dance lessons, classes, workshops, performances, karate,  fundraisers and other related activities provided by and/or at the facility of  DDCA.
The undersigned parent/student understands that students may occasionally appear in promotional performance videos, photos, brochures, and other materials as a result of his/her association with DDCA. By registering a child/student for class, such use of the child/student’s name and likeness are agreed to and acknowledged and, accordingly, all right, title and interest in same are waived.
I have read and agree to the above terms and conditions of this agreement

 dated          ____/_____/_______.
Printed Name: __________________________________

Signature: _____________________________________
(Parent’s signature if student is under 18)

 

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