Registration Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" height=82 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="0ff8dfe1esnpes.jpg"> <div> <FONT SIZE="6" COLOR="#000066" FACE="Gaslight" ><I><B><U>Bedford Dance Center</U></B></I><I><B><U> </U></B></I></FONT><B>    </B><B>|     </B><A HREF="index.htm" TARGET="_top" TITLE="Bedford Dance Center"><U><B>home</B></U></A></div> <div> <A HREF="id55.htm" TARGET="_top" TITLE="TShirt/Sweatshirt Order Form"><U>T-Shirt/Sweatshirt Order Form</U></A>   |   <A HREF="id43.htm" TARGET="_top" TITLE="Ticket Request Form"><U>Ticket Request Form</U></A>   |   <B>Registration Form</B>   |   <A HREF="id47.htm" TARGET="_top" TITLE="Video Request Form"><U>Video Request Form</U></A>   |   <A HREF="id54.htm" TARGET="_top" TITLE="Playbill Ad Form:"><U>Playbill Ad Form:</U></A>   |   <A HREF="id58.htm" TARGET="_top" TITLE="Spring Workshop Registration"><U>Spring Workshop Registration</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" height=398 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="0ff8dfc3.jpg"> <div> Registration Form</div> <div> <I><B>BEDFORD DANCE CENTER   </B></I></div> <div> <I><B>172 Route 101 ~ Bedford Village Shoppes                                                                                  </B></I></div> <div> <I><B>Bedford, NH  03110                                                                                                                   </B></I></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> (Print Form ~ Complete ~ Return to Bedford Dance Center) </div> <div> $25 Per Family Registration Fee ~ Non Refundable</div> <bR> <div> Student's Name:____________________________________________ DOB:____-____-____  AGE:______</div> <bR> <div> Parent/Guardian:____________________________________________ TEL:_________________________</div> <bR> <div> Address:________________________________________________________________________________</div> <bR> <div> E-Mail Address:_______________________________________________  Cell No:_____________________</div> <bR> <div> <B><U>Registering For</U></B><B>:</B></div> <bR> <div> <B>Fall:</B>               <B>____Intensive Division          ____Fundamentals Program</B></div> <div>  <B>________________________________________________________________________________________</B></div> <bR> <div> <B>Summer Programs:         ____Young Dancer Intensive </B><FONT SIZE="1" COLOR="#111111" FACE="Arial" ><B>(7-11 yrs)</B></FONT><B>      ____Weekly Summer Classes      </B></div> <div> <B>                                             ____Summer Dance </B><FONT SIZE="1" COLOR="#111111" FACE="Arial" ><B>(12+ years) </B></FONT><B>                                                               </B></div> <div> <B>________________________________________________________________________________________</B></div> <bR> <div> <B>Classes Interested In:     ____Ballet          ____Jazz          ____Tap     ____Modern   ____Pre-Ballet  </B></div> <bR> <div> <B>                                               ____Pointe        ____Hip Hop    </B></div> <bR> <div> <B>________________________________________________________________________________________</B></div> <bR> <div> <B><U>PREVIOUS TRAINING</U></B><B>:</B></div> <bR> <div> ________________________________________________________________________________________</div> <bR> <div> ________________________________________________________________________________________</div> <bR> <div> ________________________________________________________________________________________</div> <bR> <div> <B><U>RELEASE</U></B><B>: </B></div> <div> It shall be the responsibility of each student, participant, observer, or any other person upon the premises owned, used, or leased by the Bedford Dance Center to adhere to the policies and guidelines set forth by this studio.  Neither the Bedford Dance Center, Karen Pariseau, individually or any other instructor or agent of the Bedford Dance Center shall be liable for any loss or damage to property or bodily injury or death of persons occurring in an activity of the Bedford Dance Center, or related thereto.  All damages arising from injuries suffered during activities of the Bedford Dance Center shall be the sole responsibility of each student, a student's parent(s) or a student's guardian(s), whether or not caused or not caused by the negligence or fault of the Bedford Dance Center, Karen Pariseau, or any other agent of the Bedford Dance Center.  I/We understand that images and/or likenesses may be used for advertising or promotional materials.</div> <bR> <div> Parent/Guardian Signature:___________________________________________     Date:___________</div> </td> </tr></table></body>