Tuition payable to Pat Smith
Parent’s Last Name________________________Parent's First Name_______________________________
Home Address__________________________________City____________Zip______
Email
Address__________________________ Cell Phone___________________________
Work Phone___________________________ Home Phone____________________________
1st Student’s Name______________________________Age____D/O/B___/___/___
Class name_________________________________________Day____________Time__________________________
Class
name_________________________________________Day____________Time__________________________
2nd Student’s Name_____________________________
Age____D/O/B___/___/___
Class
name_________________________________________Day____________Time__________________________
Class
name_________________________________________Day____________Time__________________________
3rd Student’s Name______________________________Age____
D/O/B___/___/____
Class
name_________________________________________Day____________Time__________________________
Class
name_________________________________________Day____________Time__________________________
Name of Elementary/Middle/High School and release time for each
student__________________________________________
Comments (interest, experience,
concerns,etc.)_________________________________________________________________
How did you hear about Pat Smith School of Dance? ____________________________________________________________
Check
interest in the following classes/workshops: ٱIrish Step ٱTap ٱBreak
Dance ٱMat Pilates
ٱTumblingٱHula ٱCaribbean ٱFlamenco
ٱMiddle Eastern
ٱYouth Ballroom
ٱAdult Ballroom
ٱKids
Yoga ٱMusical Theatre
Photo
Release: Pat Smith School of dance
has my permission to display photographs of my child/children,
_____________________________________________________
on promotional flyers, web sites, schedules, and press releases.
Parent Signature _____________________________X
Release, Indemnity, and Assumption of Risk: I recognize the risks of illness and injury
inherent in any exercise or dance program, and my child/children: _________________________________________________ is/are
participating with the express agreement and understanding that I am waiving
and releasing Pat Smith School of Dance from any and all claims, except for
illness and injury directly resulting from gross negligence or willful
misconduct on the part of the School.
Parent Signature ______________________________X
Return this form with tuition and $25 registration
fee made payable
to Pat Smith.
Check#______Date___/___/___Amount______
More info: (480) 946-9269 or pat@pssod.com