Student Name:_____________________________________ D.O.B.________________

Parent(s) Name(s) 1._______________________________________________________

                              2. ______________________________________________________

Address:________________________________________________________________

Primary Email(s)__________________________________________________________

Home Phone #______________________Cell # _____________________Work #_____________________

Emergency Contact:_________________________________Phone #____________________

             Special Needs or Allergies: _________________________________________________

              _______________________________________________________________________

Class: 1._________________________________ Day______________ Time ________

           2._________________________________ Day_______________ Time________

           3._________________________________ Day_______________ Time________

  I, the undersigned, understand that dancing and all physical activity carries certain risks.  I do hereby agree to release  Dance & Theater           Arts Studios, its directors and employees, from any and all claims for personal iinjury [including all health consequences/risks associated with       Covid-19] or property loss, to myself, my caregiver and my child, sustained while participating in said classes and activities in conjunction with this   studio.  Parents are responsible to pay for any physical damage to the studio incurred by a student's negligence.

   I have read, and comply with the above statement:

                             Signature:______________________________________ Date:__________________

                SM I DEPOSIT / PIF __________ DATE__________ PAYMENT TYPE_________ CK #__________ 

                        BALANCE______________ DATE__________ PAYMENT TYPE_________ CK #__________

                SM II DEPOSIT / PIF__________ DATE__________ PAYMENT TYPE__________CK #_________

                          BALANCE_____________ DATE__________  PAYMENT TYPE__________CK#__________