Dee Dots Dance & Dojo Academy
email@example.com Registration Fee $25.00 ( per student )
Student Name(s):___________________________________D. O. B ____ _____ _______
Mom's Email: _______________________________________Dad's Email_____________________________________
State: _____ Zip Code: ______________
Mom Cell Phone: ________________________Dad Cell Phone:_________________________
Emergency Contact: ______________________________Phone: _________________________
Please circle day: Mon. Tues. Wed. Thur. Sat.
Creation Academy Student: Yes No
Class Choice 1 : _____________________________ Time: _______________________
Class Choice 2: _____________________________Time : _______________________
Class Choice 3: __________________________Time : ______________________
Return Registration 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
Printed Name: __________________________________
(Parent’s signature if student is under 18)