Please print clearly:

Student's Full Name: ____________________________________________
Age:_________M____F_____Date of Birth: _________________________
School Grade:______________E-Mail______________________________
Parent's Name:_________________________________________________
Address: ______________________________________________________
City:_________________________Postal Code:______________________
Phone: Home_____________________Work or Cell: __________________
Emergency Contact Person:___________________Phone:______________
Allergies or special care:_________________________________________

If you are not currently a student from Orillia Dance Academy please provide the following information:

Previous Dance Training:_________________________________________
Dance School__________________________________________________

Class fees are $9.00 per 45 min. class or $15.00 for both classes (1.5 hours). Please note that a minimum of 5 students are needed per class to run.

Total # of classes_____   Tuition enclosed:_________

Parent's Signature_______________________

Payment will be accepted monthly or in full by cheque or cash. All programs will run with a minimum of 5 students. If there is insufficient registration some classes may be cancelled and a credit will be applied to your account for the upcoming season.

WAIVER MUST BE SIGNED IN ORDER FOR YOUR APPLICATION TO BE PROCESSED:
PLEASE READ CAREFULLY:

For consideration of being granted student membership in the Orillia Dance Academy and other good valuable consideration (receipt of which is hereby acknowledged), I the Undersigned, hereby hold harmless and indemnify the Academy, the officers and employees thereof and any of all persons involved in teaching, study, or practice of dance arts or other activity by or made available at the Academy and any other members or students of the Academy, either jointly or severally from and against any and all claims and demands whatsoever, resulting from any action or omissions including but not limited to those claims and demands arising from any accident, illness, injury or to death of any person or persons or to any loss, destruction or damage of property resulting directly or indirectly from participation in the study, teaching or practice in dance arts or any other activity related to membership in the Academy and occurring during said participation on the premises of the Academy or anywhere else.

The undersigned understands there is a certain risk of injury in dancing activities and sports and acknowledges that it has been explained to her/him that caution and care reduce the element of danger and injury. The undersigned also understands and agrees that the Academy reserves the right, at any time, to void this membership for any action by the member, that the Academy deems undesirable. The undersigned represents that she/he is physically sound and has medical approval to proceed with normal routine exercise applicable to the dance arts.

Signature of Parent or Guardian___________________________Date_______________