Complete this form, by typing in your details.  Print the form, then submit it to ConfiDance Studio in-person, by mail or fax 519-570-9077. *Tip: Rick click this page with your mouse and select print preview. At the top select Shrink to fit, Custom, and enter 75%. The form will now fit one page for printing.

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Dance Registration Form:

Date: January February March April May June July August September October November December 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 2012 2011

Student's Name: Birth Date:

Age : Address: City:

Postal Code: Home Phone:

Parent's Name: Business Phone:

Ext. Cell:

E-mail:
If you are unavailable in an emergency we can call:

Name:

Phone Number:

Parental Release: Know all persons by these present that I / We
the undersigned, do hereby release and forever discharge ConfiDance Studio, its servants, employees, agents or invites of and from any and all claims, demands, risks or invitees of and from any and all claims, demands, risks or clauses or action of whatsoever kind or nature, arising from, or by reason of any and all known or unknown, foreseen or unforeseen, bodily or personal injury that may be sustained by myself / ourselves, my child / children or anyone in my / our care, while engaged or participating in the dance instruction / program conducted by ConfiDance Studio at the business premises known municipally as 625 Wabanaki Drive in the City of Kitchener. IN WITNESS WHEREOF I / We have hereunto set my /our hands(s) and seal(s) this day of , 20
I promise to pay any fees owing on or before the due date. 2% per month interest will be paid on balance of overdue accounts. I also, give permission for images of my children to appear on the ConfiDance Studio website.
***Type your name here and sign when you bring in the printed form
Signed: Witnessed:

For Office Use Only [To be completed in-person at ConfiDance Studio]

                       

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