Student First Name _______________________Last Name______________________ Age______

Birthdate__________ Grade _______ Home Phone________________ P.O. Box___________

Email address (if frequently used)______________________________________

Address_________________________________ City__________________ Zip Code___________

Parent Name_____________ Work /CellPhone_____________Occupation____________________

2nd Parent Name____________Phone # if other____________ Occupation_____________________

Any Medical problems, allergies, medications that we should know about_______________________

______________________________________________________________

How you can help with season/productions:

Sew _____ Make Phone calls_____ Advertising committee_____ Tickets_____

Runner____ Chaperone_____ Mailings_____ Costume Measurements_____ Office____

Assist w/ photo shoot____ Backstage Crew____ Props_____ Clean-up Crew_____

Computer Savvy_____ Usher____ Other_______________________________________


REGISTRATION IS INCOMPLETE WITHOUT SIGNATURE:

Student, or students, legal guardian if under 18, understands and agrees that in participating in any dance class, workshop, rehearsal, or performance, there is the possibility of physical injury. Student agrees therefore, to assume all risks of any such injury which might occur during any and all Canepa School of Dance (CSD) classes, rehearsals, workshops, or performances, and exempts, releases and indemnifies, the CSD, it's owners, instructors, guest artists from any and all liability claims, demands,, or causes of action whatsoever from any damage, loss or injury to student or student's person or property which may arise out of or in connection with participation in any classes or activities conducted by the CSD whether such loss, damage, or injury results from the negligence of CSD, its owners, instructors, or guest artists, or from some other cause.

I understand and agree to the terms set forth in the above Liability Waiver:

Signed ___________________________________________ Date ___________________


a) No refunds of tuition or costume deposit after 3rd week of session.
b) $15.00 NSF fee for all returned checks. Payment required in cash or money order.
c) All outstanding balances from previous year must be paid at registration, or student will not be enrolled.
d) All outstanding balances due, not paid by last week of class, students will not be allowed to perform in shows and no costumes will be handed out.
________________________________________________________________________________________
For office use ONLY: Form 5/04
Payment Received at Registration:

Term________ Costume Deposit_________ Other___________ Cash____ Check #_______Date________

Ballets___________new/used Jazz Shoes_____________new/used Tap Shoes Style #______________new/used

Shoes on order _____ Yes ____ No Paid in Advance? ____yes _____no AMOUNT DUE ___________

Comments:_______________________________________________Used shoes /Credit rec'd_________________

__________________________________________________________________________________________

Costume Cost___________ Tights included Yes___No____ Balance Due __________ Date paid__________