new reg form - Move Yourself Dance

Parent Information
2009/2010 Registration Form
___________________________________________
Name
___________________________________________________
Address
_____________________________ _________ ___________________ __________________________________
City Province Postal Code E-mail
______________________________ __________________________________ _____________________________
Home Phone Work Phone Cell Phone
Emergency Contact
______________________________________________________
Name & Relation
_________________________________________
Contact Phone Numbers
Student Information
____________________________________________ ______/______/________ (Date of Birth) ____________
Name DD MM YYYY Age
________________________________ ____________________________________ _________________________
AB Health Care # Doctor’s Name Doctor’s Phone
__________________________________________________________________________________________________
Medical Concerns/Allergies
__________________________________________________________________________________________________
Requested Classes
Class Name Years of Experience in this Discipline Tuition
Tuition Total

Payment
Registration Fee
Registration fee is $35 per student
For families with 3 or more children there will be a flat rate of $90
Sessional students are not required to pay registration fees
Registration fees are non-refundable with the exception of insufficient class enrollment
Tuition Fee
Tuition payment must be made at the time of registration. Payment can be made in full or in 9 equal post-dated cheques
dated September through to May
Please make cheques payable to Move Yourself Dance Ltd.
A $20 administration fee is charged on all NSF cheques
Move Yourself Dance Ltd. requires a minimum enrollment of 5 students per class, in most cases. Move Yourself Dance
Ltd. reserves the right to cancel classes that have insufficient enrollment after registration. Full refunds will be issued in
these circumstances
Withdrawal Policy
Move Yourself Dance Ltd. will retain one month’s tuition in the event of withdrawals from class(es)
Move Yourself Dance Ltd. requires written notice of a student’s withdrawal
There will be NO REFUNDS if dancers withdraw from classes after December 1, 2009.
(Once costumes have been ordered, dancers are responsible to pay for costumes)
I understand and agree to the terms listed above.
______________________________________________
Parent Signature
_______/_______/______
Dated
For Office Use
Registration Fee
Total Tuition Fee
5% GST
Total Fee
Payment method
Cheque #s

Move Yourself Dance Ltd. Release, Waiver and Indemnity
This signed release must be completed and submitted with registration package before participation in classes or activities at
Move Yourself Dance Ltd. is permitted. Thank you!
For minor children: I, _________________________________________, the parent/legal guardian of
(print parent name)
____________________________________________(the “Participant”):
(print child’s name)
For adults: I, ________________________________________________(the “Participant”) an adult over 18,
(print 18+ name)
acknowledge and agree to the following:
The Participant is physically fit and I know of no medial or health reasons why the Participant should not participate in Dance
Programs, other than as disclosed in writing to Move Yourself Dance Ltd.
Move Yourself Dance Ltd. is not responsible for persons not participating in its Dance Programs, including Participants’
parents, siblings, friends and family members, nor for guests of Participants
I accept for myself, the Participant, my other children or guests who may attend Dance Programs or Move Yourself Dance Ltd.
activities, all risks and hazards associated with participation in the Dance Programs.
Dance programs can involve use of other recreational facilities including outdoor facilities and parks, stages, gymnasiums and
various performing venues.
I agree to hold harmless and indemnify Move Yourself Dance Ltd. from any and all liability for any property damage or
personal injury to the third party resulting from my or the Participant’s involvement in the Dance Program offered by Move
Yourself Dance Ltd.
Warning: By signing this agreement, you and your personal representative give up your right to bring a court action against Move
Yourself Dance Ltd., its members, officers, directors, employees, agents and independent contractors (together referred to as “Move
Yourself Dance Ltd.”) to recover compensation for any accident, injury, loss or death to yourself or your child or damage or loss to your
property arising out of your use of Move Yourself Dance Ltd.’s facilities and your participation in programs conducted by Move Yourself
Dance Ltd., whether in the main studio location or elsewhere. You confirm that dance and recreational activities have inherent risks and
you have full knowledge of the nature and extent of the risks associated with dance and related programs and activities (together referred
to as “Dance Programs”)
I grant permission for the Participant to participate in Dance Programs under the general supervision of Move Yourself Dance Ltd. As
set out in this document and including the statements and the release contained in the Warning above, I fully release and indemnify
Move Yourself Dance Ltd. from any responsibility for recovery of loss or damage including damage to any other party resulting from
the Participant’s involvement in the Dance Programs offered by Move Yourself Dance Ltd. Intending to be legally bound, I have read
this RELEASE, INDEMNITY, AND WAIVER OF LIABILTY and fully understand this document dated
____________________________________, 20______.
_____________________________________________
Parent/Guardian Signature
Photo Waiver
I give permission for my child’s photo to be used in the promotion of the Dance Program with Move Yourself Dance Ltd.
_______________________________________________
Parent/Guardian Signature