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Summer 2012 Registration Form

To register online, please fill this form out completely. Your credit card will not be charged until you hit the “Submit Registration” button on the last screen.

DANCER’S INFO
Dancer’s Name First:   Last: 
If Musician, Instrument of Choice
Grade Entering Sept. ’12
If Preschool, Date of Birth / /
Address (incl. apt. #)
City   State   Zip
Family E-mail address
PARENTS’ INFO
Required if dancer is under 18 and/or still living at home.
Mom's Name First:   Last: 
Mom's Phone Numbers Home:   Work:   Cell:
Dad's Name First:   Last: 
Dad's Phone Numbers Home:   Work:   Cell:
EMERGENCY INFO
This information is used in the event that we CANNOT reach a parent.
Emergency Contact Name First:   Last: 
Emergency Contact Phone
Relationship to Dancer
Doctor’s Name First:   Last: 
Doctor’s Phone
CREDIT CARD INFO
Card Type
Card Number
Name on Card
Expiration Date /

Summer programs are non-refundable.

DISCLAIMER OF LIABILITY

I, on behalf of the parties hereby registered, authorize A Dancer's Dream, Inc. & TAGteach International, LLC the use of the registered party’s image for educational and promotional purposes.  Further, A Dancer’s Dream, Inc., TAGteach International, LLC, their associates & assigns are not liable for personal injuries, loss of or damage to personal property.  Since dance is a physical activity, injuries may occur.  Each student may decline to participate in any activity which may be harmful & is responsible to inform the instructor, in writing, of any physical limitations which may prevent full participation in class or any associated event.

By checking this box, I release all liability and compensation as stated above.

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