Dee Dots Dance Academy

                                 Fall Registration 2019-20


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


Student Name(s):___________________________________________________


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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