Fox Hill Dance Academy, Inc. REGISTRATION FORM
Date: _______ EACH STUDENT NEEDS A REGISTRATION FORM
Student name _____________________________Age _______
Address_____________________________ Zip code__________
Telephone #____________________
e-mail ______________________________(important)
Emergency tel.#________________________
address__________________________________________
Parent/Guardian name _________________________________
Classes: Ballet__; Tap__; Hip hop/Jazz__; Pre-School__; Other:___
Class day and time: _______________________________________
Class teacher: _____________________________
Class fee: __________
Registration fee: $25.00 per student
Enclose your personal check and write your drivers license number on the check. Or use the convenience of a charge card:
Master card__ Visa__ Discover__ Card#______________________
Expiration month _____ year ______ V code on back_____________
Signature ______________Injuries/Waiver of Liability/Authorization:
"I understand that there is a risk of potential injury associated with dance classes and performances. I represent the above named student is in good health and physically capable of participating in dance classes, performances, and recitals. On behalf of myself and the above-named student, I hereby waive and release any claim against the Fox Hill Dance Academy and/or Instructors of Fox Hill Dance Academy Inc., arising out of a personal injury occurring in connection with dance classes, performances, or otherwise occurring in or around the dance school or other locations of performances or recitals. I accept responsibility for obtaining appropriate accident, health and hospitalization insurance to cover the student in the event of personal injury. In the event of an injury or other medical emergency if I can not be reached; I authorize a staff member of Fox Hill Dance Academy to seek any medical assistance required." Your Initial ___
Signed___________________ date ________________
Mail Registration Form to: Fox Hill Dance Academy, Inc. 2275 Fox Hill DriveIndianapolis, IN 46228
Fox Hill Dance Academy
2275 Fox Hill Drive
Indianapolis, Indiana 46228
www.foxhilldanceacademy.com
317-251-3007
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