Registration

First Name:

Last Name:

Student Date of Birth:

Street:

Postal Code:

City:

Your Email Address:

Parents Names:

Telephone:

Cellular Phone:

Emergency contacts and phone
numbers if you are unreachable:

Emergency Phone 1:

Emergency Phone 2:

Years of Dance Experience:

Previous School:

Classes Desired

Time:

Day:

Subject:

Time:

Day:

Subject:

Time:

Day:

Subject:

HEALTH/WAIVER OF CLAIMS/CONSENT:

I warrant that I have no disability, impairment or ailment that prevents me from engaging in the activities herein described. This representation is made by me knowing that J & D Dance Academy of Reading will rely upon it in allowing me to participate in studio activities. I expressly agree that my use of and/or attendance at the Academy are undertaken at my sole risk and that the Academy’s owners, managers and employees shall not be liable for any damages or injuries to me or my property or be subject to any claim, demand or cause of action, including for any injury or damage resulting from then negligence of the Academy, its Management of other Academy guests. I consent to pictures being taken of me by the Academy for advertising purposes and website use only and understand that such pictures will become the property of the Academy. Where the participant listed above is a Minor (under 18 years old), I, as the minor’s parent or legal guardian, expressly agree to the Health/Waiver of Claims/Consent provisions contained above. I authorize the Academy and its Management to obtain medical treatment for my dependent minor.

REFUND POLICY: Tuition is collected monthly and quarterly. Should a student leave part way through, the unused portion will be refunded.

Please approve Health Waiver and Consent form in order to complete registration.

Health Waiver Consent:
Yes, I approve
No, I do not approve

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