Keri LaGrand Master Class
Start Date/Time: End Date/Time:
Fee per Student: Room:
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Family Information
First Name:* Last Name: *
Home Phone: Cell #: Work #:
Email: (Emails are kept confidential)
Address: *
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Emergency Contact Info*
Students entered below will be added to your family's account
I want to pay cash before the workshop.
How did you here about the workshop?
What studio are you affiliated with?
Additional Information:
I am aware that my fee will be deducted from my debit/credit card with this registration unless specified in the question section. I am aware that cash or debit/credit cards are accepted only. I am aware that checks are not accepted for workshops.
I've read the above and agree.
All Fees are non-refundable and due upon registration
I've read the above and agree.
As the legal parent or guardian, I release and hold harmless Machita Dance Company, LLC its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of Machita Dance Company, LLC its owners and operators or in route to or from any of said premises.
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: *
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