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__________