Registration

Please complete the form below

Name (Student 1)

First Name

Last Name

Date of Birth (Student 1)

YYYY

Name (Student 2)

First Name

Last Name

Date of Birth (Student 2)

YYYY

Name (Student 3)

First Name

Last Name

Date of Birth (Student 3)

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Parent/Guardian #1 Name (if student under 18)

First Name

Last Name

Parent/Guardian #1 phone number

(###)

###

####

Parent/Guardian #2 Name (if student under 18)

First Name

Last Name

Parent/Guardian #2 phone number

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact phone number

(###)

###

####

Prior Dance Experience

How Did You Learn About Us?

Please list medical conditions (including food allergies and/or drug allergies) and medications (with instructions) that would create any restrictions, limitations, or considerations in class:

Physician's Name and Phone Number

Preferred Medical Facility and Phone Number

Health Insurance Company and Phone Number

Health Insurance Policy Number

If I am unable to be contacted in the event of an emergency, I hereby authorize Conservatory of Dance Arts (CDA) or its representatives to secure any and all emergency medical treatment deemed necessary for me or my minor child/ward’s immediate care, and I agree that I will be responsible for the payment of any and all hospital and/or medical charges incurred. I agree to hold CDA and its representatives harmless for exercising its judgment in authorizing such emergency treatment forms on my behalf. By entering my name below, I authorize that I am legally responsible for the Student named in this form and grant my entry of such the full weight of my signature.

I understand that all monies paid for tuition and other fees are non-refundable.

Yes

I agree that the school is not liable for any damages or injuries sustained in connection with my training at CDA.

Yes

I agree to comply with all policies of CDA and understand that any violations of said policies may lead to suspension or expulsion from the program without refund.

Yes

I understand that any pictures and/or videos of me and/or my child taken in connection with CDA classes and events may be used by CDA without compensation.

Yes

Requested Level

Please provide the level that you expect (student 1) to be registered for, as well as any additional information that you feel is important for class placement. Final level placement is solely at the discretion of the Ballet Master.

Requested Level

Please provide the level that you expect (student 2) to be registered for, as well as any additional information that you feel is important for class placement. Final level placement is solely at the discretion of the Ballet Master.

Requested Level

Please provide the level that you expect (student 3) to be registered for, as well as any additional information that you feel is important for class placement. Final level placement is solely at the discretion of the Ballet Master.

By entering my name below, I authorize that I am legally responsible for the Student named in this form and grant my entry of such the full weight of my signature.

** A $25 Service Charge will be assessed for any Returned Checks. ** ** Payments for services rendered not received within 10 days of the date due will be subject to a $15 Late Fee. ** ** Payments for services rendered not received within 30 days of the date due may be submitted to collections. ** Waiver, Release and Indemnity: In order to participate in any activities related to Conservatory of Dance Arts (DBA Three Rivers School of Dance, herein “CDA”), Parent and/or Legal Guardian and/or Student (herein defined as “Student”) acknowledges, understands, consents and expressly agrees to all of the following: 1) All CDA classes, events and other activities are potentially dangerous and could result in injury, disability, property damage, paralysis, or death. Student voluntarily agrees to assume all risks and responsibility for any injury or loss, however caused and whether caused in whole or in part by the negligence of CDA. 2) Dance instruction involves correction of student’s form and alignment and may involve physical touch between students and instructor. Contact of this nature is both necessary and appropriate for the student’s correct development and safe training. Students with any concerns should address them to the Ballet Master. 3) Student hereby exempts, releases, and indemnifies CDA, its owners, agents, volunteers, assistants, employees, guests, faculty members, and/or students (herein collectively referred to as “Releasee”) from all liability claims, demands, or causes of action whatsoever from any damage, loss, injury, or death to Student, Student’s children, or property which may arise out of or in connection with participation in any classes, events or other activities conducted by CDA. Student further voluntarily agrees to waive their rights and that of their heirs and assignees to hold the Releasee liable for such damage, loss, injury, or death caused or alleged to be caused in whole or in part by the negligence of the Releasee or otherwise. Student expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the Commonwealth of Pennsylvania and if any portion is held invalid, it is agreed that the balance shall, notwithstanding continue in full legal force and effect. If Student makes a claim against any of the Releasees, Student will reimburse the Releasee for any money paid to or on behalf of the Student and hold Releasee harmless. By signing this document, Student hereby executes this waiver and release. Student agrees they have read this release, waiver, and indemnity, assume all risks, and fully understand its terms, understand that they have given up substantial rights by signing and have signed freely and voluntarily without any inducement, assurance or guarantee being made to them and intend their signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. ADDITIONAL TERMS AND CONDITIONS 1) Payment in Entirety: By registering, Student agrees to pay all fees in advance for services rendered and shall not be relieved of financial obligations to make any payments of the tuition fee herein agreed to. Student agrees to reimburse CDA the fees of any collection agency, which may be based on a percentage at a maximum of 50% of the debt, and all costs and expenses, including reasonably attorneys’ fees, CDA incurs in any collection efforts. 2) Policy Compliance: Student agrees to comply with all “Policies” of CDA. Policies are available in the Student Handbook and may also be given orally or posted at CDA. Failure to comply with any Policies may lead to disciplinary action, including but not limited to, temporary suspension or expulsion from the program without refund. 3) Image Waiver: Student hereby consents to and authorizes the use and reproduction by CDA of all photographs, recordings, videotapes and/or other reproductions of Students likeness for any purpose, whatsoever, without compensation. All images shall constitute the property of CDA, solely and completely. NOTICE OF CONSUMER RIGHTS 1. If the School is closed for one (1) month or more, you are entitled to your choice of either a prorated credit to your account or a prorated refund. If the closing is not the fault of CDA, CDA is entitled to choose either remedy. 2. If you become disabled for at least two (2) months during the registration term you will be given a prorated credit to your account equal to amount of time lost or the remainder of your registration period, whichever is lower. If the disability lasts for more than one (1) year, you will instead receive a prorated refund for the remainder of your registration period. To receive a credit or refund, you are required to contact the School Office and provide written verification of the disability by a physician. 3. You may cancel this agreement without penalty or further obligation within three (3) business days after the date of this agreement. Notice of cancellation must be in writing and delivered in person or by certified or registered mail. If you cancel, you are entitled to a full refund of all monies paid in this agreement. Parent/Legal Guardian (Student if over 18) agrees to all terms and conditions.

Registration

Conservatory of Dance Arts

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