Name of Student-__________________________________________________

Age-_______________Birthdate-______________Home Phone-_____________

E-Mail-___________________________________________________________

Billing Address-_____________________________________________________

City-_______________________Zip-________________________

Mother's Name-____________________________________________________ 

Employer-________________________________Work Phone-______________

Father's Name-_____________________________________________________

Employer-________________________________Work Phone-______________

Emergency Contact-(other than Parent-________________________________

Phone-______________________________

I am aware that during the dance activities that my child participates in, certain risks may occur, including, but not limited to, falling or slipping to the floor, running into other participants and activities that may result in various injuries.  In recognition of these risks, I hereby agree not to hold Linda Larma & Daughters Academe of Dance, Linda Larma, Her Teachers or Employees liable for any injuries that may occur during participation of said activities.  I hereby give my consent of my Son/Daughter to participate in the above activity.  I hereby stated that minor is physically able to participate.

I have read and agree to the policies of Linda Larma & Daughters Academe of Dance.


Parent or Guardians Signature-____________________________Date-_______

Class Day-______________________ Time-________________

Location (circle)    Studio  or  Daycare

If daycare, please indicate-_____________________________________

Have you ever been in dance before?  Yes -  No How Long-___________