COLUMBUS DANCE THEATRE

Student Information and Registration Form

Please print clearly.

Student Name:____________________________________________________________________________

Student Age:   _____________________________

Date of Birth: d_________    m________     y________

Program: _________________________________

Address_____________________________________________________________________________________________________

City: _________________________________   State:____________________________   Zip:______________________________

E-Mail address__________________________

Mother’s Name: ________________________________________

Home phone number (_____) – _______ – __________

Work phone number: (_____) – _______ – ___________

Cell phone number   (_____) – _______ – ____________

Father’s Name: _________________________________________

Home phone number (_____) – _______ – ___________

Work phone number: (_____) – _______ – ___________

Cell phone number   (_____) – _______ – ____________

Emergency Contact Person: ___________________________________________________________

Contact phone number: (_____) – _______ – _________                                            Relationship:

Release:

In consideration of Columbus Dance Theatre accepting my child / myself in the School of Columbus Dance Theatre, I do hereby waive and release all actions, claims, and demands for any damage, injury or loss to person or property which may be sustained by myself, my child, and / or my ward directly or indirectly during the course of or as a result of participation in the Columbus Dance Theatre’s program.

This waiver and release includes, but is not limited to, actions, claims and demands based on the negligence of Columbus Dance Theatre and / or by the agents, employees or directors of this institution.

I further understand that this release and indemnification shall be binding on myself, my assigns, my children, and / or wards and my personal representatives and heirs.

_____________________________________________

Signature (of Parent or Guardian)

Date

Release

I give Columbus Dance Theatre permission to use any photographs, television  or video footage of my child / myself taken while in class, performance or other Columbus Dance Theatre activity for use in publications, advertisements or other promotional purposes.

_____________________________________________

Signature