Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Emergency Contact Info
Students entered below will be added to your family's account
Please list which private lesson package you would like to purchase 1) One 1 hour lessons- $75 2) One 30 minute lessons- $45 3) Five 1 hour lessons- $340 4) Five 30 minute lessons- $195*
I understand that my card on file will be charged the day I register for private lessons which I have selected and authorized CDA to charge.*
Please list an emergency contact name and number (other than that of the parent listed on the registration form) in case of an emergency.*
I understand that if I do not give 24 hour cancelation notice to the instructor and do not attend my lesson I will be charged and not refunded the money as the teacher has blocked that time and studio*
If you have a preference of instructor, please provide their name below. If you don't have a preference please put N/A. *
Additional Information:
Liability Release
I understand and acknowledge that there is a risk of injury inherent in dance and fitness activities and that personal injury and/or damage to property may result during participation in dance and fitness related activities. I release Cumming Dance Academy, Inc. officers, staff, owners, and faculty of all injury, medical bills, damage to property, and loss of personal items occurring in or around the studio premises or at any functions held at other locations.
I've read the above and agree.
Assumption of Risk
I agree to assume all risks associated with my dancer's or my participation in class, rehearsal, stunts, and fitness performance related activities. My student or myself is covered under the adequate insurance policy carried by the legal guardian/parent.
I've read the above and agree.
I give permission for CDA to use any photos taken either at performances or in class on the CDA website or social media for publicity. No names will be used.
I've read the above and agree.
I understand that by signing my name below I am bound to this contract and all the agreements listed above.
I've read the above and agree.
Enter your Full Name: *   
Other Questions/Comments:
Credit Card Verification:
Card Number: *  
Name as it appears on card: *
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*