Online Registration

2016-2017 Online Registration Form

Upon submission of your registration forms, you will receive an email confirmation with information concerning a registration fee and choosing a payment plan which must be completed and returned to reserve class placement.  Class schedules will be emailed the last week of August to all registered students.

Dancer Information - Section I
Dancer's Name *
Dancer's Name
Home Phone
Home Phone
Address
Address
Billing Address if Different
Billing Address if Different
Parent Information - Section 2
Mother's Name
Mother's Name
Mother's Work Phone
Mother's Work Phone
Mother's Cell Phone
Mother's Cell Phone
Father's Name
Father's Name
Father's Work Phone
Father's Work Phone
Father's Cell Phone
Father's Cell Phone
Emergency Contact
Emergency Contact
Emergency Phone
Emergency Phone
Classes Desired | Dance History - Section 3
2016-2017 Classes Desired
Authorized Persons to Transport Your Child - Section 4
List the individuals authorized to pick up and drop off your child to and from dance.
Driver 1
Driver 1
Phone
Phone
Driver 2
Driver 2
Phone
Phone
Driver 3
Driver 3
Phone
Phone
Parent or Gaurdian Electronic Signature
Parent or Gaurdian Electronic Signature
Date
Date
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
2016-2017 Online Health Questionnaire - Section 5
Medical History
My permission is granted for Becky Robinson or other staff persons of Becky’s Dance Studio to obtain necessary medical attention in case of sickness or injury to my child.
Parent of Gaurdian Electronic Signature
Parent of Gaurdian Electronic Signature
Date
Date
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 or injury while participating in dance classes at Becky’s Dance Steps Studio.
Photo Release - Section 6
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
Parent or Gaurdian Electronic Signature
Date
Date
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.