Dancer's Name: _____________________________________ Birthday: _____________
Phone #�s: (Home) _____________/(Cell) _________________/(Work)_______________
Emergency contact: (Name) __________________(Relation)__________(Phone #)__________
For dancers under the age of 18, please fill out the following:
Mother�s Name: __________________________________________________________
Mother�s Phone #�s: (Home) _____________/(Cell) ____________/(Work)_____________
Father�s Name: __________________________________________________________
Father�s Phone #�s: (Home) ____________/(Cell) _____________/(Work)_____________
Class Info: (Title)_______________________(Day)__________(Time)__________________
2nd Class Info:(Title)_______________________(Day)__________(Time)__________________
|Which Part(s)?||1 or 2||1 or 2|
____ Late Enrollment Week 2
|____ Adult Dance Card|
Today's Date:____________ Amount Paid:___________ Payment Method: cash/check/credit card
I agree to pay all fees for dance class enrollment before my first class meeting starts and I understand that no payment equals no dance class. I and my heirs, executors or other representatives, hereby indemnify, release and hold harmless Yvette Corvo Misner, and Dynamic Dancing with Yvette (it�s employees and instructors) from any and all claims of liability arising from any accident, personal injury, death, or property loss or damage sustained by myself, my child(ren) or any student who is a minor while participating in dance class(es), or while on off-site trips, performances, or activities. I understand that dance activities have inherent risks of injury and being fully aware of all risk, I consent to have my child(ren)/myself participate in the programs offered by Yvette Corvo Misner, and I accept full responsibility for providing adequate health and accident insurance coverage for both my child(ren)�s protection, as well as my own. By signing this statement I declare that my child(ren)/I is(are)/am in good health, with no physical conditions that might prevent participation in dance activities.
I have carefully read this Agreement, Waiver, Release, & Assumption of Risk and fully understand its contents. I understand that this is a release of liability and sign it of my own free will.
Signature: _________________________________________________ Date: __________
In the event that Dynamic Dancing with Yvette/Yvette Corvo Misner takes video footage and/or photographs of students during dance classes and/or performances, the video footage and/or photographs will be used for the purposes listed:
1) Photos of the dancers - without their names - will potentially be used for newspaper articles/ads, on flyers, on brochures, in programs, on the Dynamic Dancing web page, and on displays at performances; and
2) Video footage of the dancers performing may be displayed on the �TV� system in the main office of the Woodland Parks, Recreation and Community Services Department.
We, the undersigned, give our permission for photos and video footage that includes ourselves and/or our children to be used in the manner stated above. We and our heirs, executors or other representatives, hereby indemnify, release and hold harmless Yvette Corvo Misner and Dynamic Dancing with Yvette for any misuse of said photos and video footage by third parties.
|Signature of Adult Dancer or Parent/ Legal Guardian of Underage Dancer||Date|
1) How did you find out about this dance class?
2) Why did you sign up for the class/what are you hoping to acheive in this dance class?
(Fun/exercise/new experience/work on dance technique)_______________________________
3) Do you want to perform? (circle one) Yes/No
4) Students with good weekly attendance will typically take 9 months to a year in progressing from one level to the next. Is this progression a priority for you? Yes/No
5) Do you currently plan to attend classes (circle one): a) for half a session, b) during certain times of the year (4-6 months), c) on a regular long-term basis (1 year or longer), d) do not know.
6) What must the class include for you to consider making it a permanent part of your schedule?