Unbound Dance Academy

Freedom to Express, Freedom to Grow, Freedom to Excel

Unbound Dance Academy LLC

1181 Hooksett Road

Hooksett, NH 03106

603-714-2821

REGISTRATION FORM

Fall 2018-June 2019


STUDENT NAME: ____________________________________________________________________________________ DATE OF BIRTH: _______________________________________________________

PARENT NAME_________________________________________________________________________________________________________________________________________________________________________________________

ADDRESS: ______________________________________________________________________________________CITY: ______________________________________________________________ZIP: _________________________

TELEPHONE: ______________________________________________________________ EMAIL: ______________________________________________________________________________________________________________

HOW DID YOU HEAR ABOUT US?________________________________________________________________________________________________________________________________________________

Please tell us of any dance experience you have had: ______________________________________________________________________________________________________________________


Dance Classes Registering For:

1_________________________________________________________________________ 5________________________________________________________________________ 3___________________________________________________________

2_____________________________________________________________________ 6_______________________________________________________________________ 6________________________________________________________

3_________________________________________________________________________ 7_______________________________________________________________________ 9____________________________________________________________

4_______________________________________________________________________ 8______________________________________________________________________ 12_________________________________________________________


Are there any special needs/medical conditions? YES NO If Yes, Please Explain:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Who should we contact in case of emergency? _______________________________________________________ Telephone: ____________________________________________________


I, the undersigned, do hereby waive all claims against the owner, instructors, and assistants, individually or otherwise, of Unbound Dance Academy LLC for any injuries he/she may sustain while attending or participating in said programs. In the event that my child sustains an injury requiring immediate medical attention, I understand that Unbound Dance Academy LLC. will make every reasonable effort to contact the individual noted above. However, in the event that the emergency contact cannot be reached, I do hereby grant Unbound Dance Academy LLC. the authority to administer first aid and/or contact emergency personnel.




___________________________________________________________________________________

           Signature (Parent or Guardian)


RECITAL PARTICIPATION: Our end of the year recital in June is a part of our program. A 40.00 costume deposit will be due in October 2018 for all performing dance classes. The 30.00 balance of the costume will be due in February 2019. PLEASE SUBMIT IN WRITING IF YOU DO NOT INTEND ON YOUR CHILD’S PARTICIPATION IN RECITAL.


PHOTO RELEASE: Unbound Dance Academy may take photos or video to promote the studio. Photos may be published in our program literature, on our website, or used on local television stations or in local newspapers. Please check one of the following and sign below.

I give permission for photos/ videos to be taken


_______________________________________________________________________________________                                                                          ______________________________________________________________

        Signature (Parent or Guardian)                                                                                                                          Date