Class Registration

 
Contact Information
Student Full Name:
Birthdate:
Parent /Guardian:
Address
E-mail *:
Phone *:
Additional Emergency Contact and Phone number :

General Release Form Please read carefully and be aware that in signing up and participating in the above program, you will be waiving and releasing all claims for injuries arising out of this program that you or the above participant might sustain:

I do hereby fully release and discharge El Alma de la Luna its officers, and employees from any and all claims from injuries, damage or loss which I (or dependents under 18 years of age) may have or which my accrue to me (or dependents) on account of my (their) participation in the above El Alma de la Luna Dance Studio sponsored activities. I further agree to indemnify and hold harmless and defend El Alma de la Luna , its officers, agents, servants, and employees from any and all claims resulting from injuries, damages, and losses sustained by me (or dependents under 18 years of age) and arising out of, connected with, or in any way associated with these activities sponsored by El Alma de la Luna Dance Academy

Yes / No permission is given for any pictures, video and or audio taken of my child to be use for publicity. I hereby agree to pay a monthly fee of $60.00 for ten months unless I choose to leave the program

Notes: