WESTMINSTER DANCE COMPANY REGISTRATION / INFORMATION FORM

5915 Westminster Blvd. Westminster, CA 92683 714) 89-DANCE or 714) 893-2623

STUDENT NAME: _________________________________

DATE: __________/________/________

ADDRESS: ___________________________________________________________________________

E-MAIL ADDRESS: ______________________________

CELL PHONE: ______________________

BIRTHDATE: _______________________HOME PHONE:_____________________________

S.S. # (STUDENTS OVER 18) ________________________ ______________________________________________________________________________

IF STUDENT IS UNDER 18 PLEASE FILL OUT THE FOLLOWING:

MOTHERíS NAME: ___________________________________S.S. #___________________________ MOTHERíS WORK PHONE: _____________________________

FATHERíS NAME: ____________________________________S.S.#___________________________

FATHERíS WORK PHONE: ______________________________ _____________________________________________________________________________________ NAME OF PERSON TO CONTACT IN CASE OF EMERGENCY: ___________________________________________

PHONE: __________________________________

IS STUDENT CURRENTLY ON ANY MEDICATION? CIRCLE: YES OR NO

IF YES, PLEASE LIST_________________________________________________________________

ARE YOU ALLERGIC TO ANYTHING? _________________________________________________

HEALTH INSURANCE: _________________________

POLICY #_____________________________

FAMILY DOCTOR: ____________________________

PHONE: _______________________________

HOW DID YOU FIND OUT ABOUT WESTMINSTER DANCE COMPANY? ______________________________________________________________________________

STUDENTS UNDER 18 PARENT MUST SIGN: IN THE EVENT OF AN EMERGENCY, AND I CAN NOT BE REACHED, I HEREBY AUTHORIZE SASHA SAMODOUROFF, OR ANY OTHER AUTHORIZED ADULT IN ASSOCIATION WITH WESTMINSTER PERFORMING ARTS CENTER, TO ACT ON MY BEHALF TO PROVIDE EMERGENCY MEDICAL TREATMENT FOR MY CHILD FROM A LICENSED MEDICAL PROFESSIONAL. LIABILITY DISCLAIMER - WESTMINSTER DANCE COMPANY AND THE INSTRUCTORS ARE NOT LIABLE FOR PERSONAL INJURIES OR LOSS OF, OR DAMAGE TO PERSONAL PROPERTY. WESMINSTER DANCE COMPANY RESERVES THE RIGHT TO USE PHOTOS OR VIDEOS OF THE STUDENTS FOR ADVERTISING PURPOSES. EACH STUDENT MAY DECLINE TO PARTCIPATE IN ANY ACTIVITY. PLEASE INFORM INSTRUCTOR OF ANY PERSONAL LIMITATIONS YOU MAY HAVE. IF YOU HAVE ANY DOUBT TO YOUR PHYSICAL ABILITIES, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE PARITICIPATING. I HAVE READ AND UNDERSTAND THE RULES, DRESS CODE AND TUITION POLICIES OF WESTMINSTER PERFORMING ARTS CENTER. I HAVE RECEIVED A COPY OF THE RULES, DRESS CODE AND POLICIES.

 

PARENT SIGNATURE: ________________________________________________________________ DATE______________