Registration
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Event:
Start Date/Time:
End Date/Time:
Fee per Student:
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- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
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Parent
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Cell #:
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Email:
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Address:
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City:
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Emergency Contact Info
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Students entered below will be added to your family's account
Add New Student #1:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #2:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #3:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #4:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #5:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Questions/Options:
Do you wish to be evaluated for the TMB Company Level for the 2024-2025 Dance Season?
*
Yes
No
Are you planning to participate in both days of the intensive? If not, which day will you attend?
*
Additional Information:
Liability Release
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I understand that dance is physically demanding and that injuries do occur. I understand that the potential dangers include but are not limited to temporary or permanent bodily injury and any associated impairments or limitations on the ability to participate in dance or other activities in the future.
I acknowledge that The Movement Box Dance Studio, LLC has made prudent efforts to inquire about my ability (or the ability of the minor named) to safely participate in activities sponsored by The Movement Box Dance Studio, LLC. I warrant that I have informed The Movement Box Dance Studio, LLC of any concerns that may impact my ability (or the ability of the minor named) to safely participate in activities sponsored by The Movement Box Dance Studio, LLC. I understand that I am under continuing obligation to inform The Movement Box Dance Studio, LLC if any additional concerns arise regarding my ability (or the ability of the minor named) to safely participate in activities sponsored by The Movement Box Dance Studio, LLC and that The Movement Box Dance Studio, LLC is under no obligation to make additional inquiries regarding this matter.
I hereby voluntarily agree (on my behalf is I am 18 years of age or older, or on behalf of the minor named)to defend, indemnify, release and otherwise hold The Movement Box Dance Studio, LLC harmless from and against any and all losses, claims, damages, liabilities, obligations, suits, actions, proceedings, costs, disbursements, and expenses (including, without limitation, attorneys' fees) of any kind or nature whatsoever, including tort, personal injury, illness, disease and medical by whomever asserted which arise from my participation (or the participation of the minor named) in activities by The Movement Box Dance Studio, LLC.
I certify that I am 18 years of age or older and am competent to contract in my own name, or that I am the parent or legal guardian of the minor named.
I've read the above and agree.
Photo Release
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I grant permission to The Movement Box Dance Studio, LLC and its agents or employees, to use photographs taken of me or the minor named for use in studio publications including but not limited to brochures, newsletters, and magazines, and to use the photographs on display boards, and to use such photographs in electronic versions of the same publications or on web sites or other electronic forms or media, and to offer them for use or distribution in other non-studio publications, electronic or otherwise, without notification to me or any other person.
I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph, and if signing on behalf of the minor named, I waive all such rights on behalf of the minor named.
I hereby agree on my own behalf if I am 18 years of age or older, or on behalf of the minor named, to release, defend, and hold harmless The Movement Box Dance Studio, LLC. and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.
I am 18 years of age or older and I am competent to contract in my own name or I am the parent or legal guardian of the minor child named. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
I've read the above and agree.
Enter your Full Name:
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Exp Year:
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City:
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