Avant-Garde School Of Dance ::

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______________

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?__________________________________

Payment Method:

Check (make payable to Avant-Garde School of Dance) ______

Visa____ Mastercard____

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.*