Class

Please Submit Us Your Registration Form by Clicking Submit Bottom in Below.

* Required Field

Address:

Student name:

Birth date:

Email:

Emergency phone number:

Phone:

Were you referred?

If yes, by who?

Class intend to join:

Date and time:

Do you have any dance experience or training in
years prior? If yes, please give a length of time.

Parents/Guardians give permission for name,
address and phone number to be published in
news or studio related purposed only. Initial:

Does your child suffer from allergies, hay fever, epilepsy, or any other
disability, including sports injuries, which you feel the staff should know of
about?

Doctor's Name:

Doctor's number:

Questions, comments:

Medical release Form:

Medical Release in case of Emergency . If I cannot be contact in the event of an emergency, I hereby authorize Flying Fairies Dance Group or
its appointed representative to sign for medical care. I hereby give my permission to be treated by a medical professional recommended by
Flying Fairies Dance Group. In the event of a non-emergency medical situation, Flying Fairies Dance Group may recommend a medical
professional for care. The decision whether to consult a medical professional for non emergency care will be my decision.

Parent/Guardian Name :

Date:

Health Insurance name
and address:

Policy Number

Parents/Guardians are responsible for co-payment amount if required by the attending physician Liability Waiver I understand that
Flying Fairies Dance Group is not responsible for any injuries sustained prior to the beginning of classes. I recognize that my child’s
participation may expose him/her to the risk of injury or harm. I accept this risk and hereby release Flying Fairies Dance Group, its
agents and employees from all liability for personal injury, illness, or property damage occurring during instruction or performance..
I understand that the studio is not accountable for any injury, illness, or property damage occurring during instruction or
performance. I certify that my child is in good health and capable of participating in all of the activities and classes.. I fully understand
that the use of alcohol, tobaccos, illegal drugs and/or demonstration of unacceptable standards of behavior will result in the
dismissal of my child from the studio with no tuition refund. Flying Fairies Dance Group has my permission to take photos, videos
and/or films of my son or daughter and consent to use such materials for promotional purposes by Flying Fairies Dance Group.