Jody's School of Dancing
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Please print all the information required below. Please bring this to the studio or mail it along with
the appropriate registration fees, first month's tuition and costume fees.

Name: ________________________________________________________________________

Street: ________________________________________________________________________

City: _____________________________________ Zip Code: ___________________________

Phone: ___________________________________ Child's Birth date: ___________ Age: _____

Physical Restrictions: ____________________________________________________________

Emergency Contact: _________________________ Phone: ____________________________

Mother's Name: ___________________ Home Phone:______________ Work:_____________

Cell Phone: _______________________ E-mail Address: ______________________________

Father's Name: ___________________ Home Phone:______________ Work:______________

Cell Phone:_______________________ E-mail Address: ________________________________

Classes enrolled for (please circle classes of your choice):

Pre-ballet  Ballet Pre-tap Tap

Jazz Pointe Acrobatics

Hip-hop Adult Lyrical

Other__________

 

Liability Disclaimer:

Jody's School of Dancing and its teachers are not liable for any personal injury, loss or
damage to personal property. Please inform your instructor of any physical limitations
you may have. Students should decline to participate in any activity which could be harmful.

Picture/Video Release: I hereby give permission for images of my child, captured during regular classes, rehearsals, performances and special activities through video & photo, to be used solely for the purposes of promotional material, newsletters, websites, and publications and waive any rights of compensation or ownership thereto.

Signature of Parent or Guardian: _________________________________________________

How did you hear about us? _____________________________________________________