We Can Dance TOO! Registration Form for January 2009 to March 2009

Dear Parent,

Thank you for your interest in our program. In order for us to make sure we have enough room for all of the people interested please complete provide us with some information.

Class is open to children with any mental, physical or learning disability. Children will engage in 45 min group sessions that will focus on muscle strength and self confidence. Some support is available at each session. We do encourage that parent enjoy this with there kids.

* Required

Parent Name * First and Last Name

Student Name * First and Last Name

Date of Birth/Age * Accepting Ages 4-12

Male/Female *

Girl
Boy

Male/Female *

Girl
Boy

Mailing Address * Street Address

City/State/Zip *

Home Phone *

Cell Phone *

Email Address *

Medical Problems/Health Concerns * It may be necessary to stay the first class to give instructors any special care instructions for your child.

Emergency Contact Person * If other than parent

Emergency Contact Telephone * If other than parent

Name of Class * Currently only one offering

Payment * Payment accepted in cash/check on day of class or mail to address listed above. Please make checks payable to : Lakerry Dawson

* No Refunds given after first week of classes * I, the adult applicant or I, the parent or legal guardian of the applicant listed below, hereby give approval of the applicant’s participation in any and all We Can Dance TOO! programs and activities registered below. I do waive, release, absolve, indemnify and agree to hold harmless the organizers, sponsors, supervisors, participants and persons involved in the operation of We Can Dance Too!, Inc. programs for any claims arising out of injury or other loss to named applicant or any member of his/her family whether as a participant in the activities or as a spectator. I also give permission for We Can Dance TOO!, Inc. to take photos of me or my child to use for the website and for purposes of promoting the Dance Class . If any child exhibits behavior that is dangerous to herself/himself or to other students, The We Can Dance , Inc. reserves the right to remove the child from the Class. Please enter your name and birth date as acknowledgment and acceptance of the above statement. If you have any questions please feel free to contact us.