Main Street Dance Registration

 
Address *
Address
Home phone number *
Home phone number
Mother's work phone number
Mother's work phone number
Mother's cell phone number
Mother's cell phone number
Father's work phone number
Father's work phone number
Father's cell phone number
Father's cell phone number
Phone number (emergency contact #1)
Phone number (emergency contact #1)
Phone number (emergency contact #2)
Phone number (emergency contact #2)
Classes registering for:
RELEASE: By signing below, I do hereby release Main Street Dance and their agents of representatives of liability for my child of any injury to my child in class or while on the school campus. I understand that in the event medical intervention is needed, every attempt will be made to contact me. In the event next of kin cannot be contacted, for the health and well-being of my child, I hereby authorize the Staff or Instructors of Main Street Dance to authorize whatever medical treatment might be necessary in an emergency situation. I understand that I and my medical insurance carrier are financially responsible for any medical treatment extended to my child and that Main Street Dance and its agents or representatives cannot be held accountable or liable for much medical treatment. By signing below, I grant to Main Street Dance its employees, agents, and assignees, the right and permission to make, reuse, and/or publish photographic pictures or video tapings of me/my child, which may be used in connection with my/my child’s own or a fictitious name, for any purpose whatsoever including the use of any printed matter. I waive any right to inspect or approve either the finished photograph or video or the printed matter or video with which it may be used in conjunction.
Release Agreement
 
 

Prefer to bring in a paper copy of the registration form?