Centerstage Dance Academy
Registration Form 2012-2013
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.
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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