Registration
Already a customer? Click here to login.
Emersyns party is going to be a bibbity bobbity blast! Guests may arrive in their princess dress (or pirate, knight, prince, etc. costume if they prefer). Mom and dad can dress up too… that’s optional of course! Please just fill out the form below and click submit.
Event:
Start Date/Time:
End Date/Time:
Fee per Family:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Caregiver
Father
Guardian
Mother
Parent
Self
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Emergency Contact Info (Not Contact #1 or #2)
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Questions/Options:
Child's full name:
*
Girl / Boy :
*
Additional Information:
Liability Waiver
(Show-Hide Details)
I understand that there are risks of physical injury associated with, arising out of, and inherent to the activity of dance. In recognition of this acknowledged risk of injury, I knowingly and voluntarily waive all right and/or causes of action of any kind, including any and all claims of negligence arising as a result of such activity from which liability could accrue to David Kieffer LLC doing business as The Dance Connection, it's officers, agents, employees, instructors, subsidiaries, parent corporations, and all affiliated entities (hereinafter collectively referred to as "The Dance Connection"). I hereby agree to release The Dance Connection and hold The Dance Connection harmless of all liability, and hereby acknowledge that I knowingly and voluntarily assume full responsibility for all risks of physical injury arising out of active participation in dance on behalf of myself or my minor child. I am aware that this is a release of liability and an acknowledgement of my voluntary and knowing assumption of the risk of injury. I have signed this document voluntarily and of my own free will in exchange for the privilege of participation. I have had an opportunity to discuss this release with an attorney before signing it if I chose to do so.
I've read the above and agree.
Enter your Full Name:
*
Other Questions/Comments:
Please Wait...
