Student's name:

Student's date of birth:

Parent or Guardian's name(s):

Full address:

Home phone number:

Cell phone number:

E-mail address:

Years of dance:

Prior studio name(s): (If applicable)

List of any student injuries or allergies:

What class or classes you are registering for:

Classical BalletPointeJazzTapHip HopMusical TheaterClogging

Agreement

I do hereby agree to the following rules and requirements to Pisgah Dance Academy at 6850 Asheville Hwy, Pisgah Forest, NC:

- No food or drinks on the dance floor (water only)
- No street shoes on the dance floor in the large studio
- Children should not be left along outside unsupervised at anytime. This includes dancers as well as siblings or friends.
- Please respect the ground with no littering.

I do hereby relinquish Pisgah Dance Academy, PC Builders, and property owners of the facility from any liabilities as a result of injuries or negligence at said porperty pertaining to my family or acquantainaces that are rpesent on said property. This also applies at venues where the two recitals are held annually. I authorize and allow PDA to use pictures or video for advertising purposes of my child.

Signature: