The Cornerstone Studio Inc. Online Registration

Registration

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Cornerstone Studio Registration Form

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Client Information

Family Last Name*

Where do you live?

Home Address*

City*

State/Prov*

Postal Code*

Home or Primary Phone*

Additional Info

Emergency Contact Info*

Contact #1

Contact #1 First Name*

Last Name *

Type*

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)

Additional Info

Student Email

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies*

Enroll in Classes

Select Another Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies*

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

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

Additional Info

Student Email

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies*

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

RELEASE OF LIABILITY AND CONSENT

The Cornerstone Studio Inc. ("Company")

IN CONSIDERATION of participation in the program, classes, workshops, use of equipment and related activities, I, the undersigned, acknowledge and agree that:

I fully understand the nature of participation in classes, workshops or any and all activities offered by the Company and agree to accept the risks inherent in physical activity. I, therefore, freely assume all risks, known and unknown, and assume full responsibility for my participation or attendance and hereby release and forever discharge the Company from any and all claims, demands, losses or liability arising out of or related to any personal injury, loss or damage to person or property that I may suffer and agree to hold the Company harmless in the event of any such event or occurrence.

I further understand that it is my responsibility to consult with a physician prior to and regarding my participation in classes, workshops or events offered by the Company I represent and warrant that I am physically fit and have no medical condition that would prevent my full participation in said classes, workshops, or events.

In signing below, I further agree that I have read the Company's Policies and Procedures and agree to abide by the Policies and Procedures incorporated by reference to this agreement. I further understand that the Company follows PIPEDA legislation with respect to privacy. The Company takes all reasonable steps to protect the personal information of its participants. I hereby agree to hold the Company harmless for any breach, howsoever caused, of security resulting in the release of personal information.

CONSENT

By signing below, I further grant and convey any right, title and interest in and to the Participant's name (first name, last initial), voice or statements including any and all photographic images and video and audio recordings made by the Company or its agents or employees for advertisement or publicity purposes for the Company.

I HAVE READ THIS RELEASE OF LIABILITY AND CONSENT AGREEMENT AND FULLY UNDERSTAND ITS TERMS AND CONDITIONS:

I've read the above and agree.

POLICIES AND PROCEDURES

Please read Cornerstone Studio's Policies and Procedures here for all adult and youth programs and commitments.

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/Prov

Postal Code*