2010 Summer Studio Registration Form

Student Name: ___________________________________ Date of  Birth: ____ / ____ / ____

Dance start date: ________________________  Check one:  Male:   ÿ     Female:   ÿ    

Primary Contact: ___________________________ Relationship: _____________________

Address: __________________________ City: ______________ State: ____ Zip: ________

Home Phone: __________________ Work Phone: _________________

Cell Phone: ___________________

Email Address: _____________________________________________________________

Would you like to receive special announcements and bulletins via email?   Yes: ÿ  No: ÿ 

Was student previously enrolled at WEBBY Dance Company?   Yes: ÿ  No: ÿ 

Pertinent Medical Info: _______________________________________________________

 WAIVER AND RELEASE:

                 I, the undersigned, hereby acknowledge that I have voluntarily applied for the services of WEBBY Dance Company dance classes, which are conducted at 6975B Dixie Highway, Fairfield, OH 45014.

                 As lawful consideration for being permitted to participate in this program, I hereby agree that I, my heirs, distributees, guardians, legal representative, and assigns will not make a claim against, sue, attach the property of, or prosecute WEBBY Dance Company, or any

of its members for any injuries or damage resulting to me, my child, or my property from the negligence or other acts, however caused, by

any member, agent, employee, or contractor of WEBBY Dance Company, as the result of my participation in this activity.

                  In addition, I hereby release and discharge WEBBY Dance Company and its members from all actions, claims, or demands I, my heirs, distributees, guardians, legal representatives, or assigns now have or may in the future have for injury or damage resulting from my participation in this activity.

                   I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS.  I AM AWARE THAT THIS IS

A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND WEBBY DANCE COMPANY AND/OR ITS MEMBERS -- AND I

HAVE SIGNED IT OF MY OWN FREE WILL.

Photo Advertising Release: I give my permission to WEBBY Dance Company to use my child’s

photograph for advertising purposes. I understand that my or my child’s name will not be used

in any way. Photos may be used in brochures, information packets, posters, and on our web site.

Yes: ÿ  No: ÿ

DATE: _____ / _____ / _____     SIGNATURE: ______________________________________________

TUITION RATES – DANCE STUDIO
  

Tuition for weekly classes:

 $46.00 per month (class time 50 minutes)

   Toddler classes (30-36 months of age) 30 minute class - $36.00 per month

6975 B Dixie Highway, Fairfield, Ohio 45014    Phone: 513-942-0100    Fax: 513-942-0707