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Student name:
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Student birthdate:
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Parent name(s):
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eMail address:
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Add to eMail
mailing list:
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How did you hear
about us?:
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Phone number:
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Work/Cell number:
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Full Address:
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Emergency Contact:
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Relationship:
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Emer. Cont. Phone:
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Fall Session (Sept-Dec)
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Winter Session (Jan-May)
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Class(es)/Day/Time:
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Option 1 - Pay in Full:
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Option 2 - Payment Plan:
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Credit Card Info:
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Credit Card Expiration:
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Electronic Signature:
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Subtotal:
Registration Fee:
Option to add costume:
Authorized to charge-
TOTAL:
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By typing your initials here, you agree to the waiver below.:
All students, parents/guardian are aware of possible injury that may occur during any creative art class,
performances or rehearsals and are willing to assume those risks. All students, parents/guardian
understand that it is their responsibility to consult a physician prior to and regarding their participation
in any of Kerry’s Dance Stages classes. I, my heirs or legal representative forever release, waive,
discharge and covenant not to sue Kerry’s Dance Stages (including directors, officers or employees) for
any injury or death caused by their negligence or other acts beyond their control. I have read the above
waiver of liability and Kerry's Dance Stages Policies and fully understand and agree to its contents. I
voluntarily agree to the terms and conditions above and agree to pay all fees associated with classes,
outlined on pricing schedule. We give Kerry’s Dance Stages permission to use pictures and/or videos of
our children for advertising purposes.
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When you click "Submit", your Registration will be
sent. A Confirmation e-mail will be sent to you.
Please check your junk mail folder if you haven't
received confirmation within 48 hours.
Thank You!
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