3004 S. Rancho Dr. Las Vegas, NV * PH: *

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1 2009/2010 Policy Agreement I have received a copy of the 2009/2010 studio policy and current class schedule. I agree to adhere to all studio policies as contained in this document and explained to me. I also agree to follow any further policies that may be deemed necessary throughout the year. Both parent and student should read carefully and acknowledge with a signature. This includes but is not limited to the following (please initial each): Due Options: $65 a month with a one year commitment. *dues must be paid regardless of attendance $25 extra class $75 a month for a month-to-month commitment. $45 a month for Keikis $85 Fireknife Training DUES are paid in advance, due on the 15 th $15.00 late fee (no exceptions). of month, and late after the 25 th. Tuition after the 25 th must include the DUES are due each and every month including months with holidays and event performance, DUES are non-refundable and non-transferable. There are no refunds, credits, or extensions given for any reason. Make up classes, when available, are for currently enrolled students only and must be taken within 4 weeks of missed class. DRESS CODE AND UNIFORM to be adhered to at all times. Please refer to the policy for your class specifics. APPROPRIATE BEHAVIOR is expected at all times towards Tevakanui staff, other students and visitors to the school. NO CELL PHONES the practice area. All cell phones must be turned off or set to silent during practice times. NO FOOD OR DRINK with the exception of water are in the studios. Do not bring gum on the premises. It is the member s responsibility to bring their own water to practice. TEVAKANUI assumes no liability for any injury sustained while participating in dance classes or while in the studio premises. I release Tevakanui and its representatives from any liability due to any injury that may occur when participating in strenuous activity such as dance. I allow Tevakanui use of my dancer s name and photographic likeness in all forms and media for advertising, and other lawful purpose. Please initial: Yes, I accept No, I Decline Parent Signature Date Student Signature Rep Signature

2 New Re Apply Class Membership Application Today s Date: First Name: Last Name: Middle Initial: Address: Primary Phone: City: Zip Code: Address: Date of Birth: Age: Gender: Month Day Parent/Guardian Name: Phone: (if under 18) Member Information Describe your medical condition: (Circle One) Excellent Good Fair Poor Do you have Health Insurance: (Circle One) Yes No Member/Policy number: Insurer Name: Company: Allergies: Are you on any Special Medication: Hobbies: Special Interest:

3 Have you had any Polynesian Dance Lesson? (Circle One) Yes No with Whom Are you enrolled with any school or sports activities? (Circle One) Yes No with Whom In Case of Emergency: Name: Relationship: Phone Number: Name: Relationship: Phone Number: Other Immediate Family Members that are ACTIVE in Tevakanui: Mama) Name: Class Category: (Drumming, Keiki, Junior, Senior Boy or Girl, Hot I received a copy of my policy agreement and my binder. I have paid the registration fee along with the first month.

4 Member Agreement, Disclaimer and Hold Harmless Agreement I, agree to attend classes on a monthly basis and pay for my monthly Students Name tuition in the amount of $ to Tevakanui. I agree to a agreement with TEVAKANUI in which I agree to pay every month on the 15 th of the month. If paid after the 25 th of the month I agree to a $15 late fee. If this is a 12 month commitment I agree to pay monthly for a period of 12 months and should I cancel after the 10 th of the month I agree to pay a $65 buy-out fee. I understand and accept that to enter into a 12 month agreement dues must be paid through electronic funds transfer ie. Credit Card or Debit. If you agree, initial each box below: I agree to pay a $15.00 late fee for my monthly dues if paid after the 25 th of the month. I agree to pay an additional $15.00 late fee for any costumes that are not paid for by the specific due date set by Tevakanui. I understand that if I take a break from Tevakanui for more than one month I will need to re-apply and therefore be charged the current rates set by Tevakanui, along with a $15.00 re-application fee per member. 1. In consideration for receiving permission to participate with Tevakanui, I, Hereby RELEASE, WAIVE, DISCHARGE, and COVENANT not to sue, the staff of Tevakanui-Polynesian Club and their committees, officers, agents, volunteers or employees (herein after referred to as Releases) from any loss damage or injury, including death that may be sustained by myself, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise while participating in such activity, or while, in on, or upon premises located at the address where the activity/classes is being conducted. 2. I hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage or costs, including court costs and attorney fees, that they may incur due to our organization s participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF same RELEASEES or other wise. 3. I realize that Tevakanui-Polynesian Club and their committees does not maintain insurance policy covering any circumstance arising from the participation in this event or any activity associated with or facilitating that participation. As such, we are aware that we should review our own personal insurance portfolio. 4. IN SIGINING THIS RELEASE, WE ACKNOWLEDGE AND REPRESENT that we have read the foregoing Hold Harmless Agreement, understand it and sign it voluntarily as our own free act and deed: no oral representatives, statements, or inducements, apart from the foregoing written agreement, have been

5 made; our authorized representatives that has signed below is at least 18 years of age and or accompanied by an adult and fully competent; and executes this release for full adequate and complete consideration fully intending to be bound by. I authorize TEVAKANUI to use EFT for my monthly dues in the amount of $ every month on the 15 th of the month or shortly there after. If I choose to cancel prior to the ending of this agreement I must cancel in writing in person or by certified mail and include a $65 buy-out. If I cancel before the 10 th of the month I understand that I will not be charged for the current month and will still be responsible for the buy-out fee. Signature/Date Rep Signature/Date Credit Card Number Exp Date Name As It Appears on the Card Verification Code Print Name Student Signature Student s Signature Print Name Parent/Guardian (If under 18) Signature Parent/Guardian Signature Students Name: Class Category Monthly Membership Dues: 1 st day of Instruction begins: Tuition Per Student Dancer Per Month: *Dues subject to change with 30 day notice *$55.00 Keiki Class *$65.00 Per Class

6 *75.00 Month to Month *$25.00 Extra Class Tuition is discounted for immediate family members at $5.00 after the $65.00 rate. There is a one time application processing fee of $25.00 per student, which includes: A Student Handbook (3 pronged binder), Introduction Sheet, Rules and Regulations, Basic Steps w/definition Please make checks payable to: Tevakanui LATE FEES: ($25.00 returned check fee) *A $15.00 late fee will be assessed for tuition dues paid after the 25 th of the month. **An additional $15.00 late fee will be added if COSTUMES are paid for after the due date set by Tevakanui. ***Any member that takes a break for more than one month will need to re-apply and therefore be charged the current tuition rates set by Tevakanui, along with a $15.00 re-application fee per member! Students Class Schedule: Class Time

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