DanZQuest
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
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)
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: _________________________________________________
ALLERGES_____________________________________________________________________