Register - MAD Dance

Dancer's Name *

First

Last

Date of birth – day *

Date of birth – month *

Date of birth – year *

Address *

Email *

Home phone

Mobile phone

Classes Enrolling in

(Class / Day / Time)

First Aid Information

Does the dancer have any medical conditions or allergies ? Please describe in detail

Emergency Contact 1 *

First

Last

Phone number *

Relationship to dancer *

Emergency Contact 2

First

Last

Phone

Relationship to dancer

Disclaimer *

I agree

I hereby agree to all the terms and conditions as set by MAD Dance, I understand that no liability will be taken for the loss or damage of any property, or any physical injury caused whilst at MAD Dance premises. I also adhere to paying ALL fees on time and understand these are non-refundable. I understand that if fees go into arrears that an administration fee of $35 will occur and that tuition may be refused. I agree to give MAD Dance permission and all rights to use any photography or media recordings of students for promotional purposes. Lastly, reminder notices will be sent to families by email or text regarding important notices

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