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									                                LIFE MOVEMENT CLASS REGISTRATION/LEAD
  Life Movement Spirit and Dance Center
  6-01 Saddle River Road                                                                                    Emergency Information
  Fair Lawn, NJ 07410                                                                  Contact Name________________________Phone_________________
  Primary Adult_________________________________________
                                                                                       Does the applicant have any special medical considerations?
   Child Name ______________________________DOB______                                  __________________________________________________________
                                                                                       I understand every effort will be made to contact me, the contact person or
  Mailing Address_______________________________________                               the doctor. If we cannot be reached, I give my consent for the emergency
                                                                                       room physician to treat myself, my child or my family.
  City________________________State_______Zip____________                              Signature_________________________________________________

  Home Phone (          )______________________________________

  Cell Phone (        )________________________________________

I, the adult applicant or I, the legal guardian of the applicant listed, hereby give approval for participation in all Life Movement programs and activities. I
do agree to hold harmless the organizers, sponsors, supervisors, participants and persons involved in the operation of Life Movement LLC programs for
any claims arising out of injury or other loss to named applicant or any member of his/her family whether as a participant in the activities or as a spectator.
I also give permission for Life Movement LLC to take photos/videos of me or my child to use for the website and for purposes of promoting the school,
with no compensation due me and/or my child. If any child exhibits behavior that is dangerous to herself/himself or to other students, Life Movement LLC
reserves the right to remove the child from the school.
______________________________________________________                                                ______________
Adult Applicant or Parent/Guardian Signature                                                               Date

Email Address: _______________________________________________________________(used for Life Movement purposes only)

How did you hear about us?
Google____ Yahoo____Flyer____A Friend____ Newspaper Ad____Other_______________________________
Life Movement LLC. Reserves the right, at any time, to cancel or change classes, days and times. Bounced check fee: $35.00
Life Movement LLC has a no refund policy. Missed classes can be made up in appropriate age and level classes throughout the season.
For Office Use Only:
  Outlook:______Akada: ______ Interest E-mail:____ Thank you e-mail:_____ Step in/Phone/E-mail

  Class/classes they are interested in: _______________________________                                    Notes: ___________________________________
  Paid Demo Date: __________ Price: ______ [Visa/Master/Discover/Cash/Check#_____]                                ___________________________________
  Sign Up   Date: __________ Price: ______ [Visa/Master/Discover/Cash/Check#_____]                                ___________________________________
         Original Sign Up Class: _____________________________________

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