"Where EVERY dancer is a STAR"

Child's Full Name____________________________________________ Sex______________
Address___________________________________City__________________Zip__________
Date of Birth_____________ Height_________ Wt_________

Father' s Name________________________________________  Phone_________________
Mother's Name________________________________________  Phone_________________
Cell Phone_____________________ Email address:__________________________________

Names and ages of other children:_________________________________________________

Inoculation the child has received: DPT___Measles___Mumps___Whooping cough____
All inoculations are current: yes_____ no_____

Date of last physical examination:___________________
Child's physician:_____________________________________ Phone___________________

Would you say your child's general physical condition is good?___________________________

Please list any conditions or problems about which we should be aware (allergies, etc.)
___________________________________________________________________________

Is your child covered under an insurance plan for accidents and injury?
Insurance Company's name______________________Responsible Party___________________
If school insurance were available, would you be interested?_______________________

Emergency contact (In the event that neither parent is available): Name___________________________Phone_______________Relationship________________

Name___________________________Phone_______________Relationship________________

What goals do you hope your child attains this year in our dance education program?
____________________________________________________________________________

Class day and time______________________________________________________________

I attest that the above information is to the best of my knowledge true and correct. I give permission for my child to participate in all classes for which he/she is registered. I realize and accept that there is a certain risk involved in the participation of this program, as there would be in any physical activity. I hereby waiver and release any and all rights for damages I or my child may have against Star-Styled Dance Center, Cheryl K. O'Malley, and other staff members as such.

I understand that there will be no credit or refunds given for classes missed or if a student withdraws. Tuition is to be paid monthly according to the payment chart.  There is a $35 registration fee for any student registering after Sept. 30th.

Parent Signature________________________________________Date____________________