Taneytown Dance Center: On-Line Enrollment

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SCHOOL ENROLLMENT

MASTER CLASS REGISTRATION

DANCE COMPANY

On-Line Enrollment

Session: Summer 2010

PLEASE COMPLETE THIS 3 PART FORM IN ORDER TO REGISTER YOUR ENROLLMENT

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PART 1: CLASS SELECTION & TUITION AGREEMENT

Student's First Name Student's Last Name

Date of Birth Parent's Name

Street Address 1 Street Address 2

City State Zip Code

Home Phone Work Phone

Cell Phone Email Address

Please select from the list below the class(es) for which you are registering this student.

CLASS 1

CLASS 2

CLASS 3

CLASS 4

SUMMER SESSION COST AND TERMS

CASH OR CHECK ONLY, Please.

$20.00 Registration fee applies. ($12 for returning students)
Please Note: Registration Fees are non-refundanble

6 classes for $55 with the Live to Dance Membership Card

OR Drop-In Rate: $10 / class

The undersigned, for him(her)self and / or as the parent or guardian of the student named above (individually and collectively, the Student) assumes the sole risk of injury, accident, death, loss, cost or damage to his or her person or property which might arise from the use of Taneytown Dance Center's services and facilities, or participation in any dance / exercise course program, including the matter relating to any preexisting physical condition or impairment. The Student, his / her heirs, personal representatives, executors, employees, servants, and agents from all claims, demands, injuries, damages, actions or causes of action and from all acts of passive negligence on the part of Taneytown Dance Center, its servants, instructors, agents or employees. The Student further certifies that he or she is in good physical health and is able to undertake and engage in the physical exercise or sports activities in which he or she chooses to participate, including participation in any dance / exercise course or program.

Yes, I accept the terms above (equates to signature of Student or Parent / Guardian, if minor)

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PART 2: HEALTH INFORMATION FORM

Dance movements are strenuous. The training required of dance puts unusual and unique stresses on the body, particularly the musculoskeletal and cardiopulmonary system. Dance training requires a certain level of physical health, and requires the instructor to possess an accurate knowledge of his/her student's relative health status. In order to obtain this, I ask that you complete the following information on you (if participating in adult class) or your child. If you have any concerns or hesitations about these questions, please feel free to speak to me about it directly. Thank you, and I look forward to working with you and your children!

Miss Kim

Please list if your child has any dance experience and, if so, how much.

Is your child currently under treatment for any condition?
Yes No
If yes, please explain briefly and reference treating physician.

Has your child ever injured a bone, joint, or muscle?
Yes No
If yes, please explain briefly.

Has your child ever had surgery?
Yes No
If yes, please explain briefly.

Has your child ever experienced shortness of breath or dizziness after mild or moderate exercise?
Yes No
If yes, please explain briefly.

Please review the following list of symptoms and check appropriate responses.

Does your child now or has your child ever suffered from the following:

seizures or epilepsy

diabetes

fainting

chronic dizziness

shortness of breath

asthma or allergies*

bone or joint pain

food or medication allergies**

rheumatoid arthritis

any other condition which might affect his / her ability to train in dance

If you checked any of the above, please explain in brief detail.

* List asthma or allergy medications ** List food or medication allergies

Person, other than parents or gaurdian, to be informed in case of an emergency.

Emergency Contact Name

Street Address 1 Street Address 2

City State Zip Code

Home Phone Cell Phone

Relationship

Physician currently responsible for your child's health care.

Physician's Name

Street Address 1 Street Address 2

City State Zip Code

Phone

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PART 3: PHOTO WAIVER

Yes, as the legal Parent / Guardian of the student named above, my child may be videotaped and / or photographed for display in print, other promotional materials, or on the Taneytown Dance Center website (minors' identification will NEVER be provided on the website) - Selecting "yes" represents signature of the legal Parent / Guardian
No, as the legal Parent / Guardian of the student named above, photographs or videotapes of my child may NOT be used.

2 frederick street

taneytown MD 21787

410.756.9311

dance@taneytowndancecenter.com