Please list below any medical conditions and/or allergies the DBA Faculty should be

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1 Registration Form Name Of Child(ren): Date of Birth: Address Where Child Resides: Mailing Address (if different from above): Home Phone Number: Please check next to whom the child resides with: Mother s Name: Mother s Cell Phone: Mother s Address: Father s Name: Father s Cell Phone: Father s Address: Emergency Contact Info: Name: Phone Number: Relationship to child: Please list below any medical conditions and/or allergies the DBA Faculty should be aware of:

2 How did you hear about DBA Dance? (check any that apply) Friend/Family Referral Online (website) Facebook Newspaper Ad Other Print Ad Lawn Signs/Flyers Other (please specify): Please check the classes and/or classes that you are registering for: Giggles n Wiggles Twinkling Stars (ages 2 1/2-4) Thursday 4:00 Saturday 10:40 Tumble Tots Hip-Hop For Tots Sparkling Stars (ages 5-7) Ballet Tap Jazz Acrobatics Hip-Hop Zumbatomic Glowing Stars (Ages 8-11) Ballet Tap Jazz Acrobatics Hip-Hop Zumbatomic Shooting Stars (Ages 12-18) Ballet/Lyrical Tap Jazz Acrobatics Hip-Hop Rising Stars (Adults Ages 18 & up) Lyrical/Jazz Tap Hip-Hop DBA Boyz Crew Shining Stars Advanced Acro Workout Please indicate if you are interested in any of the following: Weekday Morning Yoga Class Weekday Morning Giggles n Wiggles Class Weekday Morning Twinkling Stars Class Family Fun Zumba Office Use Only: Registration Fee = $ is due at time of registration ($30 for one child or $50 for family registration fee of 2 or more children) Method of payment: cash check credit Check # Date on check: Type of Card: Card # Exp. Date: / Security Code: Monthly Tuition = $ (First payment will deduct on September 20th, 2015)

3 Policy Form This AGREEMENT is made and effective as of date executed by and between Dream Believe Achieve Dance ( DBA ), located at 283 Main Street ( SCHOOL ), and the adult or guardian ( ADULT ), executing this AGREEMENT personally on behalf of himself/herself and any minor child/children specified herein (collectively ( PARTICIPANTS ). DBA and PARTICIPANTS may be referred to collectively as the PARTIES. 1. WAIVER AND RELEASE OF LIABILITY. PARTICIPANTS, on behalf of themselves, their parents, spouses, children/wards, heirs, assigns, representatives, estates, successors, attorneys, insurers, and all other persons, firms, partnerships or corporations connected therewith ( RELEASING PARTIES ), forever, finally, fully, permanently and unconditionally waive, release, acquit, discharge, covenant not to sue, indemnify, covenant to hold harmless, and defend DBA and its present and former employees, owners, members, principals, directors, subsidiaries, affiliates, representatives, predecessors, successors, shareholders, partners, parents, officers, agents, assigns, servants, attorneys, insurers, suppliers, manufacturers, clients, customers, PARTICIPANTS, and all other persons, firms, partnerships or corporations connected therewith ( RELEASED PARTIES ), to the fullest extent permitted by law, from any and all charges, claims, debts, disputes, demands, suits, causes of action, rights of action, dues, sums of money, accounts, liabilities, losses, expenses and damages, absolute or contingent, known or unknown, whether or not asserted, threatened, alleged or litigated, now existing or arising in the future, at law or equity, whether caused by the negligence of RELEASED PARTIES or otherwise, that arise out of or relate in any way to PARTICIPANTS use of the equipment and facilities at the SCHOOL, participation in the activities at the SCHOOL, and any claims for costs, expenses and attorneys fees associated therewith. 2. ASSUMPTION OF RISK. Participation in the activities and use of the equipment at the SCHOOL is purely voluntary and constitutes inherently risky activities that may result in serious injury and/or property damage to PARTICIPANTS and/or third parties. Safety equipment and apparatus is provided for the protection of PARTICIPANTS, including physical contact by instructors that is reasonably intended to coach, teach or demonstrate a particular skill or to prevent or lessen injury (i.e. spotting). However, all safety risks cannot be eliminated. RELEASING PARTIES hereby assume the risk of personal injury or death, damage to property, and injury to third parties that arise out of or relate in any way to PARTICIPANTS past, present or future use of the equipment, any of the other facilities at the SCHOOL and participation in the activities at the SCHOOL.

4 3. PHOTOGRAPH RELEASE. I grant RELEASED PARTIES the right to take and use photographs of PARTICIPANTS with or without his/her name and for any lawful purpose, including but not limited to publicity, illustration, advertising, and website content so long as such photographs is used in connection with DBA. 4. Returned Checks: ADULT acknowledges that there will be a $35.00 service charge for all returned checks. 5. Cancelation Policy: ADULT acknowledges that DBA has the right to cancel and/or change class and/or class times due to the number of enrolled students in the selected course. 6. Additional Fees/Costs: Tuition does not include recital/performance costumes, recital/ performance fees, recital/performance tickets, attire (including shoes, tights, and apparel), private and semi-private classes. There are absolutely no refunds or credits given for these fees and costs for any reason. 7. Parent Photography / Videography: For the safety and privacy of our students, no photography or videography can be taken during class without the instructor s approval and may be cause to have the person leave the premises and not to return. 8. AGREEMENT. ADULT acknowledges that he/she has read and understands each and every provision of this AGREEMENT, and by placing his/her signature at the end of this AGREEMENT, represents that he/she has voluntarily assumed the obligations contained herein and intentionally waived all the rights stated herein, of his/her own free will. ADULT further certifies that he/she is a parent/guardian with legal responsibility for any minor child/children and desires that PARTICIPANTS participate in the activities and use the equipment available at the SCHOOL. Name of ADULT: Name of Minor: Date of Birth: Relationship to Minor: Signature of ADULT on behalf of PARTICIPANTS: Date:

5 Recurring Payment Authorization Form Your monthly tuition will be automatically deducted from your bank account, or charged to your Visa, MasterCard, American Express or Discover Card. Just complete and sign this form to get it started! Here s How Recurring Payments Work: You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be ed to you and the charge will appear on your bank statement as an ACH Debit. You agree that no priornotification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. Please complete the information below: I (full name) authorize DBA Dance to charge my credit card indicated below for $ on the 20th of each month for payment of my dance class tuition. Billing Address City, State, Zip Phone# Checking/ Savings Account Credit Card Checking Name on Acct Bank Name Account Number Bank Routing # Bank City/State Savings Visa Cardholder Name Account Number Exp. Date Discover SIGNATURE DATE I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify DBA Dance in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that DBA Dance may at its discretion attempt to process the charge again within 30 days, and agree to an additional $45 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

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