Starlight Dance Center
Registration and Medical Consent


Student's name ________________________________ Registration Date ____________

Student's Birthday ______________________________ Student's Age __________

Classes interested in signing up for : _______________________________________

Home Phone _______________ Cell ______________ Email _____________________

Home Address _____________________________City _____________ Zip __________

Mother's Name _________________________ Home Phone _____________________ Work Phone _____________________

Father's Name _________________________ Home Phone _____________________ Work Phone _____________________

Emergency Contact (if parents can't be reached)

Name _________________________ Phone ______________________

Relationship to student __________________________

Where did you hear about the studio? __________________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * As the parent or legal guardian, I hereby give consent to Patty Williams to provide all emergency medical care prescribed by a duly licensed physician (M.D.) or dentist (D.D.S.) for ________________________ (student's name).

This care may be given under whatever conditions are necessary to preserve the life, limb. or well being of my dependant.

Date _____________________ Parent/Guardian Signature___________________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * Does your child have any medical concerns or allergic reactions of which we should be aware?

____________________________________________________________________________
Physcian's name and phone _______________________________________________________

Any specific instructions concerning hospital or emergency procedures?
____________________________________________________________________________
____________________________________________________________________________

Starlight Dance Center
Assumption of Risk Waiver And Release of Liability


In Consideration of participating in classes at Starlight Dance Center, I ____________________________, understand there are certain risks of injury, and I am willing to assume these risks.

I hereby certify that I/my child am/is capable of participating in the activities of Starlight Dance Center and I am/my child is healthy and have no physical or mental disabilities or infirmities that would restrict full participation in dance activities except as listed below.

I hereby waive, release, hold harmless and covenant not to sue Starlight Dance Center, its officers, employees and other representatives, for all claims made on account of an injury suffered in the normal course of dancing, whether the result of negligence or any other cause.

Parent/Guardian Signature ___________________________________ Date__________________
I have read and understand this waiver and release of liability and assumption of risk.

Please list any physical limitations (allergies, hearing, sight, etc.):

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Student's name _____________________________
Parent's name ______________________________