Avant-Garde School of Dance Registration Form
Students Name:________________________________________
Students Age:__________Students Birthday _____/_____/______
Parent's Name:_____________________________________
Street Address:________________________________________________
City:_____________________________ State:_____ Zip Code:_________
Home Phone(_____)__________________Cell Phone(_____)____________________
Mother's Work Phone(_____)_______________________ext.__________
Father's Work Phone(_____)________________________ext.__________
Email:_______________________________________________________
Who may we contact, other than yourself, in the event of an emergency:
Name:____________________________ Phone(_____)___________________
List any allergies or medical conditions:_____________________________________
____________________________________________________________________
School that student attends:_________________________________________
Previous training(where, with whom, how long, and type of dance studied)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Other hobbies and/or interests:____________________________________________
_____________________________________________________________________
Classes Enrolling In
Class________________________Day_________________Time______________
Class________________________Day_________________Time______________
Class________________________Day_________________Time______________
Class________________________Day_________________Time______________
Class________________________Day_________________Time______________
Class________________________Day_________________Time______________
Class________________________Day_________________Time______________
Class________________________Day_________________Time______________
Liability Waiver
I agree that the Avant-Garde School of Dance LLC, its faculty, staff, or any of its employees shall in no way be liable to me, my child, or any other party for any injury sustained by me or my child, or any consequent losses or costs, while at Avant-Garde School of Dance.
I also indemnify Avant-Garde School of Dance LLC, its faculty, its staff, and its employees, against any claims or costs arising out of any acts or omissions by me or my child, which may be construed to have caused injury to any person while at Avant-Garde School of Dance.
I undertake to safeguard my personal property and will not hold Avant-Garde School of Dance LLC, its faculty, its staff, or any of its employees liable for any loss.
Signature_________________________________Date______________
How did you hear about AGSD?__________________________________
Accepted Payment Methods:
Cash (In a sealed envelope with students name)
Check (make payable to Avant-Garde School of Dance) ______
Credit card: Visa____ Mastercard____ Diner's Club___ (Credit card payments will be assessed an additonal 3% fee)
Card Number:__________________________________________Expires:___________
Card verification #_________
Name on Card:__________________________________________________
Please check if you would like to start automatic payment____
*Your account will be charged on the 1st of each month. You must notify the staff no later than the 15th, of the prior month, if you would like to stop automatic payments.*