Registration Form

BEDFORD DANCE CENTER   

172 Route 101 ~ Bedford Village Shoppes                                                                                  

Bedford, NH  03110                                                                                                                   

(Print Form ~ Complete ~ Return to Bedford Dance Center)

$25 Per Family Registration Fee ~ Non Refundable

Student's Name:____________________________________________ DOB:____-____-____  AGE:______

Parent/Guardian:____________________________________________ TEL:_________________________

Address:________________________________________________________________________________

E-Mail Address:_______________________________________________  Cell No:_____________________

Registering For:

Fall:               ____Intensive Division          ____Fundamentals Program

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Summer Programs:         ____Young Dancer Intensive (7-11 yrs)      ____Weekly Summer Classes      

                                             ____Summer Dance (12+ years)                                                               

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Classes Interested In:     ____Ballet          ____Jazz          ____Tap     ____Modern   ____Pre-Ballet  

                                               ____Pointe        ____Hip Hop    

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PREVIOUS TRAINING:

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RELEASE:

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.

Parent/Guardian Signature:___________________________________________     Date:___________