STAR-STYLED DANCE REGISTRATION FORM
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"Where EVERY dancer is a STAR"
Child's Full Name____________________________________________
Date of Birth_____________ Height_________ Wt_________
Father' s Name________________________________________
Mother's Name________________________________________ Phone_________________
Cell Phone_____________________ Email address:__________________________________
Names and ages of other children:_________________________________________________
Inoculation the child has received: DPT___Measles___Mumps___Whooping
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
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________________
What goals do you hope your child attains this year in our dance education
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.