Centerstage Dance Academy

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					                                  Centerstage Dance Academy
                                      Registration Form 2012-2013

Student’s Name:____________________________________________________________________

E- Mail Address:____________________________________________________________________
*Receive monthly newsletters on line

Date of Birth_______________________________________Age as of Dec 2012_______________


Parent’s Name___________________________________Home Phone_________________________

Work Phone_____________________________________Cell Phone___________________________

Emergency Contact_______________________________Relationship to dancer__________________

Emergency Contact’s Phone Number_______________________________________

Class Day and Time________________________________________________________________

Since dance is a physical activity, the possibility for injury is always present. Each student may decline to
participate in any activity which he/she feels may be harmful and is responsible to inform the instructor of
any physical limitations which may prevent full participation in class. Kathy Coughlin’s Centerstage Dance
Academy and it’s instructors are not liable for personal injuries or loss of or damage to personal property.
Special Medical Facts:__________________________________________________________________________________

I have read the rules and general information on the attached pamphlet and agree to abide by them.
Parent/Legal Guardian__________________________________________________Date_________

Please check one of the following:
_____ Centerstage may use my dancer’s picture on the website and in promotional materials. (Names will
      NOT be used)

_____ Centerstage may NOT use my dancer’s picture on the website and in promotional materials.

Parent/Legal Guardian Signature _______________________________________________________________

Registration Fee $25.00---Family Registration Fee $35.00

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