A fun filled class for you and your toddler (ages: crawling to 3). We’ll socialize, dance, juggle, learn some partner moves to try, play on mats, and give our kiddos room to explore in a safe environment with other similar aged kids. Kiddos must be accompanied by at least 1 guardian throughout the whole class. More than 1 guardian is welcome too. Wear comfy clothes you can move in and come grow your tiny human’s circus skills with a skilled professional.
Start Date/Time: End Date/Time:
Fee per Family: Room:
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Family Information
First Name:* Last Name: *
Home Phone: Cell #: Work #:
Email: (Emails are kept confidential)
Address: *
City: * State: * Zip: *
How old is your little(s)?*
How many children in your group? A. One B. Two C. Three
Additional Information:
Release of Liability
Release of Liability
As the legal parent or guardian, I release and hold harmless DanceWorX Studio, 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 DanceWorx Studio, its owners and operators or in route to or from any of said premises.

Medical Emergency
The undersigned gives permission to DanceWorx Studio, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or condition and/or declare the participant to be in good physical and mental health.

I've read the above and agree.
Media/Internet Release
Media/Internet Release
Danceworx Studio occasionally uses photos of students in both classroom and performance settings for promotional materials including newspapers, television, and the internet including our website and social media. By signing this form, Participant and Guardian are allowing DanceWorx Studio the use of Student’s image without identification.

I've read the above and agree.
Credit Card Authorization
Credit Card Authorization
As the car holder I authorize DanceWorX studio to use the card I have provided as payment for the charges under my account.

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:*