|
N-STEP DANCE CENTER Class Registration Form 2626 Brown Ave. Manchester, NH 03103 (603) 641-6787 nstepdancecenter@verizon.net Please fill out one registration sheet PER child Dancer Name:________________________________________ Birthday:___/___/____ Age: __________ Parent / Guardian: ______________________________________________________________________ Home Address: ________________________________________________________________________ City: ___________________________ State: _________________________ Zip: _______________
Home Phone: ___________________________ Cell Phone: ____________________________________ E-Mail Address: ______________________________________________________________________ Work Place: _____________________________ Job Title: ____________________________________ Work Phone:__________________________ May we contact you at work? _____________________
Emergency Contact: ________________________ Relationship: ________________________________ Phone Number: ___________________________ 2nd Number: ________________________________
Physician's Name: ______________________________ Phone: ________________________________ Insurance Company: (Required) _______________________ Policy Number: ______________________
Please list any allergies, medical conditions, or restrictions: _______________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Waiver of Injury: I the undersigned, do hereby voluntarily submit my child for attendance and full participation in the N-Step Dance Center program. I hereby assume full responsibility for any and all damages, injuries or losses that she/he may sustain or incur, in anyway, while attending or participating in any N-Step Dance Classes or Activities. I, the undersigned, do hereby wave all claims against the instructors, owners and or operators, individually or otherwise, of N-Step Dance Center, for any injuries she/he may sustain while attending or participating in said programs. I fully understand that any medical treatment given to my child will be first aid only, but I give emergency treatment authorization if I cannot be reached. This form can be photocopied for emergency treatment.
Registration fee is due with submission of this form. The registration fee is non-refundabl and non-transferable. No exceptions will be made to this policy for any reason.
By signing below I agree to all of the rules and policies set forth by N-Step Dance Center.
Parent/Guardian Signature: _______________________________________Date: __/__/__
____________________________________________________________________________ |