DanZQuest Dance Studio
Wilmington, NC

      

 

DanZQuest Dance Studio

Registration Form

 

 

        NAME:  _______________________     ________________________     ________________________                  

                                                    (FIRST)                                                            (MIDDLE)                                                            (LAST)

 

                         ADDRESS:  _____________________________________________________________________________

 

 

CITY:  _____________________________  STATE:  _________________  ZIP:  _______________

 

 

                                                     BIRTH DATE:  ____/____/____       AGE:  ______     MALE / FEMALE

 

CLASS ASSIGNMENT

 

           6 WEEK SESSION -                       CLASS __________________________            DAY/TIME________________________

 

CLASS __________________________            DAY/TIME________________________

 

CLASS __________________________            DAY/TIME________________________

 

CLASS __________________________            DAY/TIME________________________

 

 

 

PAYMENT PLAN (circle one)

OPTION (A) YEAR IN FULL                                                                                 OPTION (B) MONTHLY PAYMENTS

 

AS IN ANY PHYSICAL ACTIVITY, THERE IS A RISK OF INJURY.  DANZQUEST DOES NOT CARRY INSURANCE FOR INDIVIDUAL STUDENTS AND REQUIRES THAT EACH STUDENT HAVE THEIR OWN MEDICAL COVERAGE.  BY SIGNING BELOW I AGREE NOT TO HOLD DANZQUEST LIABLE FOR ANY PHYSICAL INJURY AND UNDERSTAND THAT ANY MEDICAL BILLS INCURRED WILL BE MY SOLE RESPONSIBILITY.

 

_____________________________________     _________________________

                (PARENT OR GUARDIAN SIGNATURE)                                                         (DATE)

 

I have read the policies of DanZQuest Dance Studio (including clothing/shoe requirements, tuition fees).   

Parent or Guardian Signature___________________________________________________________

 

Company Students/Parents -  I have read the comapny contract and I agree to the terms and conditions with in.

Parent/Guardian and Student Signature___________________________________________________________

 

CONTACT INFORMATION

 MOTHER:  __________________________                                                                FATHER:  ____________________________

  WORK/CELL:  __________________________                                                              WORK/CELL:  ___________________________

  HOME:       _______________________________                                                       HOME:    ____________________________

 

E-MAIL ADDRESS FOR DANZQUEST NEWS, ECT.   ___________________________________________________        

                             

EMERGENCY CONTACT and PHONE NUMBER:  _________________________________________________

 

 

ALLERGES_____________________________________________________________________