MNR Dance Factory Registration Form Summer 2008

Today's Date:

Student Name  

Date of Birth   Hm. Ph. #

Parent or Guardian Names:   Cell/Emerg.Phone #

Mother Wk Ph# Father Wk Ph# Guardian Wk Ph#

Address: City Zip Email

2nd Parent/Guradian Info:  

How did you hear about us? Yellow Pg Parent Mag Friend Enter Name Other

Classes: Enter Day and Time

If Summer Camp, Choose Session(s): 1st 2nd 3rd If attending special days, note which days

If Summer Intensive, number of weeks of intensive

Annual Registration Fee $35 Summer Camp Deposit $100

Method of Payment: Amex/Visa/MC (Circle one)    Credit Card #: Exp date: / 3-4 Digit Security Code If Billing Address is diferent from home address please enter address (number only) Billing Zip Code if different than home zip

Name on Card: Amount: auth to charge
I authorize MNR Dance Factory to charge my account in the second week of each Semester or 10 days after due date if payment has not been rec'vd: Yes Initial

Signature to authorize payment   Date

Are there any Allergies that we should be aware of?    Yes or No   If Yes

I am aware that my child(ren) , will be exposed to certain risks that exist in athletic activity, including safety and personal injury risk.   I am voluntarily allowing my child to participate in these activities.   I agree that I will not sue on behalf of my minor child, or otherwise make any claim against MnR Dance Factory, Inc. or any of its affiliates, employees, agents or members for any injury or damage, however caused, by the MNR Dance Factory, as a result of my minor child(ren)'s participation in a dance class or program.

Parent/Guardian Signature:             Date: