Student Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Student's Birthdate *

MM

DD

YYYY

Parent's Name *

First Name

Last Name

Parent's Name

First Name

Last Name

Checkbox

I, the undersigned, recognize the risks in the course of instruction in dance and I agree to indemnify and hold harmless STEELTOES DANCE STUDIO Inc, KATHLEEN STEAD, her or it’s agents and employees in the event that I or my child(ren) suffer injury/illness or damages while undertaking the course of instruction. I understand there are NO REFUNDS-studio credit only. I give permission for my child to appear in any promotional/social media material for Steeltoes Dance Studio, Inc. By Clicking Agree, I am electronically signing that I have read the Registration Form and have agreed to its terms.

I Agree

Today's Date *

MM

DD

YYYY