Dancer's Name
*
First Name
Last Name
Home Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Dancer's Date of Birth
*
Dancer's Age
*
Dancer's Grade
*
Dancer's School
*
Billing Address if Different
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mother's Name
First Name
Last Name
Mother's Employer
Mother's Work Phone
(###)
###
####
Mother's Cell Phone
(###)
###
####
Mother's Email Address
*
Father's Name
First Name
Last Name
Father's Employer
*
Father's Work Phone
(###)
###
####
Father's Cell Phone
(###)
###
####
Father's Email Address
Emergency Contact (other than parents)
First Name
Last Name
Emergency Phone
(###)
###
####
2022-2023 Classes Desired
Previous Dance Training
Number of Years Dancing
Studio Danced With
After School Activities
Driver 1
First Name
Last Name
Phone
(###)
###
####
Driver 2
First Name
Last Name
Phone
(###)
###
####
Driver 3
First Name
Last Name
Phone
(###)
###
####
Parent or Gaurdian Electronic Signature
First Name
Last Name
Date
MM
DD
YYYY
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
Medical History
Please explain any history checked above
Previous surgeries, injuries or serious illnesses
Any current medications and why they are being taken:
Are there any physical limitations that would affect your child’s participation in dance class? If so, what?
Parent of Gaurdian Electronic Signature
First Name
Last Name
Date
MM
DD
YYYY
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. I, the undersigned, do hereby verify that the above information is correct and I do hereby release and forever discharge Becky Robinson and the staff of Becky’s Dance Steps Studio from any and all claims, demands, actions or cause of action, past, present, or future arising out of any damage, injury, or illness while participating in dance classes at Becky’s Dance Steps Studio.
I agree that my child’s picture or likeness can be represented and published in any Becky’s Dance Steps Studio publications, advertisements, website photos, Facebook page and videos to be viewed by the public.
Parent or Gaurdian Electronic Signature
First Name
Last Name
Date
MM
DD
YYYY
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
As with the transmission of any communicable disease like the cold or flu, you may be exposed to Covid-19, also known as Corona Virus, at any time or in any place. Despite our careful attention to sanitizing, disinfecting and social distancing at BDSS, there is always the chance that you could be exposed to an illness at the studio, just as you might be at the gym, grocery store or favorite restaurant. Although we have taken extra measures to provide social distancing and contactless participation, please know that participation in BDSS classes is AT YOUR OWN RISK.
Although exposure is unlikely, do you accept the risk and consent to participation?
Parent or Guardian Electronic Signature
First Name
Last Name
Date
MM
DD
YYYY