RAINBOW DANCE ACADEMY REGISTRATION FORM

Office use Only: Pd check # ________ AMT.________ Pd cash amt ___________

First STUDENT’S NAME _____________________________ BIRTHDATE___/___/___

Last First Middle MM DD YY

STUDENT EMAIL ________________________________

SCHOOL ________________________ GRADE______ DANCE EXPERIENCE (in yrs.) ____

(Fall 2007)

Please write your First and Second Choice of Class Below.

1^st Choice Class type/name _________________________________ Day __________ Time ______________

2^nd Choice Day __________ Time ______________

1^st Choice Class type/name _________________________________ Day __________ Time ______________

2^nd Choice Day __________ Time ______________

1^st Choice Class type/name _________________________________ Day __________ Time ______________

2^nd Choice Day __________ Time ______________

_______________________________________________________________________

2^nd STUDENT’S NAME _____________________________ BIRTHDATE___/___/___

Last First Middle MM DD YY

STUDENT EMAIL ________________________________

School ________________________ GRADE______ DANCE EXPERIENCE (in yrs.) ____

(Fall 2006)

1^st Choice Class type/name _________________________________ Day __________ Time ______________

2^nd Choice Day __________ Time ______________

1^st Choice Class type/name _________________________________ Day __________ Time ______________

2^nd Choice Day __________ Time ______________

1^st Choice Class type/name _________________________________ Day __________ Time ______________

2^nd Choice Day __________ Time ______________

________________________________________________________________________

BILLING NAME _______________________________ Home Ph # (___) _____-______

EMAIL ______________________________________ Work Ph # (___) _____-_______

Do You check your email daily? __________ Cell Ph # (___) _____-_______

BILLING ADDRESS _____________________ CITY___________________Zip__________

EMERGENCY INFO:

DR. NAME__________________________ PHONE (____)_____-____

EMERGENCY CONTACT PH (____) ____-____ RELATION/Name ______________________

---------------------- *How did you learn about RDA? ________________________________

Waiver of Liability - (RDA – Rainbow Dance Academy)

I, the undersigned parent or legal guardian of the student(s) above, do hereby give permission for the aforementioned persons to participate in any and all classes, programs, shows and events offered by or attended by RDA. I accept all risks associated with that participation and understand that there is a full possibility of serious, physical illness or injury. I hereby covenant not to sue and waive, release and forever discharge any and all rights and claims for damages, which may arise now or in the future against RDA and its owners, directors, employees, and/or other assigned representatives or volunteers from any and all liability and for any and all damages and/or injuries which may be sustained or suffered by the student(s) listed above while participating at or for RDA. ) PARENT INITIAL HERE _________

Insurance & Permission for Treatment - (RDA – Rainbow Dance Academy)

My Signature below indicates my certification that I have medical insurance on the student(s) listed above and will maintain continuous medical coverage while he/she dances at RDA. I also authorize RDA and its owners, employees, directors, etc. to use standard first aid procedures on the student(s) listed above and to consent any other medical procedure that is deemed necessary in the case of an emergency. Furthermore, I certify that I personally and/or my medical insurance carrier will be responsible for all expenses which are incurred in relation to any injury sustained during any RDA related activity including but not limited to RDA class, competition, show, etc. (Please list your medical coverage information below and let RDA know if changes occur.) PARENT INITIAL HERE _________

Insurance Company Name _____________________________________ PolicyHolder Name ______________________________ Policy # _____________________

Photography and/or Video Release - (RDA – Rainbow Dance Academy)

I hereby give my permission to RDA for appropriate use of photographs of the student(s) listed above for RDA website, photo galleries, and program books, and promotional offers (such as fliers, mailings, advertisements . PARENT INITIAL HERE ___________________

Parent or Legal Guardian Signature ________________________________________________________