Registration Form

form per dancer)

NAACHDUNIYA DANCE COMPANY

Registration form

2010 - 2011 Session

Student Name __________________________________________________

Age _____ Birth date ___________

Street Address __________________________________________________

City ___________________________________________________

State _______ Zip ___________________

Contact/ Emergency Information

Parent or Guardian _______________________________

Daytime Phone _________________________

Evening Phone ________________________

Cell Phone ________________________

Email Address _____________________________________

Person responsible for payment (if not same as above) ________________________________________

Emergency Contact (other than parent/guardian) _____________________________________________

Relationship to student ________________

Phone ______________________Cell Phone ___________________

Are there any medical or behavioral conditions that we need to be made aware of? If so, please describe below:

 

　

Dance History

New students - How did you hear about us? ___________________________________

Is this the student’s first year of dance? ________

Years of dance training completed _______

Former dance school(s) _____________________________________

I ___________________________ have enrolled

_________________________ in a program of strenuous physical activity,

Parent name Student name

offered by NaachDuniya Dance Company/ Vikashni Prasad. I hereby affirm that I am or the above person is in good physical condition and does not

suffer from any disability that would prevent or limit participation in this dance program. In consideration of myself, my heirs and assigns, hereby release the NaachDuniya Dance Company, the owner Vikashni Prasad, her family, her employers from any claims, demands, and causes of action arising from my or the above named person’s participation in any of the above stated programs,

and I hereby release the NaachDuniya Dance Company, the owner Vikashni Prasad, her family or employees, from any liability now or in the future including but not limited to heart attacks, muscle strains, pulls, tears, broken bones, shin splints, heat prostration, knee, lower back, or foot injuries and any other illness, soreness or injury however caused occurring before, during or after participation

in any other of the above stated programs offered at NaachDuniya/ Vikashni Prasad or at any time, while in the vicinity of the premises of

the above stated business, or in any activity sponsored, represented, or organized by NaachDuniya Dance Company, the owner Vikashni Prasad, her family, or employees, for any reason. By signing, I hereby affirm that I have read and fully understand and agree with the above waiver.

Signature of Parent/ Guardian ________________________________

Date _____________________

New student

Returning student

I am enrolling __________________________________ for NaachDuniya Dance Company / Vikashni Prasad. I understand

Student name_________________________________

that tuition is based on a every 1st of the month tuition installments.

Tuition is considered late if not paid by the 1st of each month and a late charge of $15 will be strictly enforced.

There are no refunds given for any reason. I understand that if my child withdraws from the program, that all fees and deposits are 100% nonrefundable.Signature ______________________________

Date __________________

By signing this form, the parent/adult is assuming any and all responsibility for the student, including financial obligations. The parent/adult signing below has also received a copy of the studio policies, and has read and understands all policies.

CLASS REGISTRATION

Please list classes enrolling in for the Dance Year

Class 1: _____________________

Class 2: _____________________

Class 3: ______________________

Class 4: _______________________

Class 5: _________________________

* There is a $10.00 nonrefundable registration fee per family due with this form. Enrollment will not be completed until registration fee is received by mail. Thank you for registering with NaachDuniya Dance Company / Vikashni Prasad! We hope to see you soon!

Make Check Payable to: Vikashni Prasad

 

Mail forms to:

 

Vikashni Prasad 74 Dillon Ave Suite C Campbell, CA 95008

Office Use Only:

Registration fee paid ________Payment method ___________Check #_________________ Collected by __________________