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: *
Students entered below will be added to your family's account
I assume all the risks of my child participating in all activities and events through Caitlin Colleen Dance Academy. *
I certify that my child is physically fit and has not been advised to not participate by a qualified medical professional.*
I release and discharge any and all liability from all directors, instructors, and assistants and acknowledge that they are not responsible for any injury or property loss.*
I consent for my child to receive medical treatment which may be deemed advisable in the event of injury and/or accident during all activities with Caitlin Colleen Dance Academy.*
I understand that throughout all classes and events, I/ or my child may be photographed.*
I certify that I have read this document and I fully understand its content. I am aware that this is a release of liability and a contract.*
Additional Information:
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:*