REGISTRATION FORM

Registration Form

* Indicates required field

Student's Name *

First

Last

Prior Student *

Yes No

Person Responsible for Payment *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Student's Cell Number *

Mother's Name *

First

Last

Father's Name *

First

Last

Date of Birth *

Mother's Cell Number *

Work Phone Number *

Email *

Father's Cell Number *

Work Phone Number *

Email *

Age *

Grade *

School *

Next Emergency Contact *

Physician Name *

County *

Phone Number *

Allergies/Medications *

I hereby waive any claims or cause against DYNAMICS DANCE, INC. HOLLY POPE-PEDRONI for any injury or harm sustained while participating in gymnastics, dancing, or exercising at the studio located at 8970 103rd Street, Jacksonville, Florida. I fully realize and agree that my child is participating at their own risk, and I will personally bear all expenses and incur all losses for any harm or injury that may occur while inside said premises.

I HAVE ALSO READ AND AGREE TO THE PRICES, POLICIES AND PROCEDURES OUTLINED ON THE PRIOR PAGE BY DYNAMICS DANCE INC.

Digital Signature *

First

Last

Submit