Bridgets Dance Studio Online Registration

Registration

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Bridget's Dance Studio Registration Form 2018 - 2019

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier*

Contact #1

Parents First Name*

Last Name *

How Can We Contact You?

Home Phone *

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Enroll in Classes

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Enroll in Classes

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Enroll in Classes

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Enroll in Classes

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Student Email

T-Shirt Size

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies*

Medications*

Primary Doctor*

Enroll in Classes

Add Another Student

Required Policies and Agreements

Release of Liability

As the legal parent or guardian, I release and hold harmless Bridget's Dance Studio LLC, its owner, teachers 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 Bridget's Dance Studio LLC, its owners and operators or in route to or from any of said premises.

I've read the above and agree.

Signature Text

As the legal parent or guardian, I release and hold harmless Bridget's Dance Studio 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 Bridget's Dance Studio LLC, its owner, teachers and operators or in route to or from any of said premises.

I've read the above and agree.

Medical Emergency

The undersigned gives permission to Bridget's Dance Studio, its owner, teachers 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, restictions, or condition and/or declare the paricipant to be in good physical and mental health. I request that our doctor/physician ________________ be called and that my child be transported to ______________________ hospital. Please include physicians' phone number _______________.

I've read the above and agree.

ACKNOWLEDGEMENT OF ACTIVITY RISKS

I acknowledge my understanding and acceptance of the following:
1. That the activities offered by BDS include active sports which can result in injury to participants and/or spectators;
2. That BDS provides an observation area and that I have the option to remain in the observation area while my child and/or ward is in a class, working out or performing;
3. That in the event I choose to leave my child and/or ward before, during or after a class, workout or a performance, I hereby give BDS my permission to use its discretion in determining whether my child and/or ward requires medical attention and, if so, to use its discretion in transporting my child and/or ward, selecting a health care facility and obtaining treatment for him/her;
4. That in my absence BDS does NOT assume any responsibility for the care, custody, control, condition, health or well-being of my child and/or ward.

I've read the above and agree.

Automatic Payment

BDS will send out emailed statements of all tuition balances due one week prior to due date. I authorize BDS to automatically charge my card on file for tuition and merchandise payments. Auto-pay for tuition will be processed the first week of each term which includes September, December,and March. Costume payment will be authorized the first week of January. Summer session will be authorized at the time of enrollment. If another payment option is going to used, then BDS must be notified a week prior to tuition due dates. Any inquiry about statement charges must be reported to BDS a week prior to the automatic payment date.

I've read the above and agree.

Payment Information

Tuition for our regular dance season is due by the first week of each trimester which is September, December, and March. Costume fee's are due the first week of January. If accounts are paid after the tenth of the month, there will be a $15.00 late fee applied to the account balance. There is a $30.00 returned check charge for any checks returned by the bank. Tuition payments will remain the same regardless of Holiday's, school vacations, and bad weather.

I've read the above and agree.

Withdrawal

We understand issues arise that may require a student to withdraw from class. If this would occur, we require a 15 day written notice prior to their anticipated last class. If a written notice is not received, tuition will continue to be billed until one is received. All tuition and costume fees are non-refundable and must be paid in full by their anticipated last class - if not, tuition will continue to be billed until final payment is received. If your child is not going to participate in the end of year recital we must have written notice 15 days prior to the January costume payment. If we do not receive written notice 15 days prior we will assume your child is participating in the performance and you will be responsible for your costume payment as well as tuition until the end of class date.

Bridget's Dance Studio reserves the right to withdraw a student from class/studio in the event that:
-they exhibit unsafe behavior toward themselves, our students, Instructors, staff and all family members
-they use foul language, suggestions, or negative behavior around our students, Instructors, staff and all family members
-they continuously fail to follow directions from an Instructor or staff member
-they are more than two months behind in their tuition or costume payments
-if a student or a family member creates a negative scene or argument for our students, Instructors, staff and all family members
-if a student or a family member refuses to cooperate with the guidelines set forth by "˜Bridget's Dance Studio'

I've read the above and agree.

Notices

As the legal parent or guardian, it is my responsibility to read all notices sent out by the dance studio, check the studio lobby for posted information, and read all emails that may contain important information about recital dates, deadlines, and more. A Copy of all letters sent home will be posted on the bulletin board located in the lobby, sent by email, or placed on our website: www.bridgetsdancestudio.com

I've read the above and agree.

USE OF IMAGES/NAME IDENTIFICATION –

I authorize BDS to use images in print and on the internet of me and/or my child and/or ward, both with and without name identification, for BDS publicity, promotional and advertising purposes and release any and all claims and/or rights I and/or my child and/or ward might have as a result. I authorize BDS to take pictures of my child and post them, either in print form or online.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*