Registration Class Registration Form Participant's Name(Required) First Last Participant's Birthdate(Required) MM slash DD slash YYYY Participant's School Participant's Grade Level Class informationClass Registering For(Required)ZumbiniDance w/MeCreative MovementAnts in your PantsBatonPomsMusical TheaterHip-HopTurns and JumpsBeginning Adult Ballet / JazzPre-Ballet and TapBallet and TapBalletTapLyricalBeg PointePointeJr JazzJazzSr JazzClass Level(Required)IIIIIAIIBIIIIVClass Day(Required)MondayTuesdayWednesdayThursdayFridaySaturdayClass Time(Required)AMPMParent InformationParent / Guardian Name(Required) First Last Parent / Guardian Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent / Guardian Phone(Required)Parent / Guardian Email(Required) Parent / Guardian Name 2 First Last Parent / Guardian Phone 2Parent / Guardian Email 2 Emergency Contact InformationPlease List 2 Emergency ContactsName First Last PhoneRelationship to Participant Name First Last PhoneRelationship to Participant Consent and Waiver InformationParticipant Liability Waiver and Hold Harmless Agreement(Required) I agree to the Participant Liability Waiver and Hold Harmless Agreement.As a participant or participant’s parent/legal guardian, I understand that by participating in any class, rehearsal, or performance, there is a possibility of physical injury. I, therefore, agree to assume all risks of such injury which might occur during any classes, rehearsals, or performances of Miss Becky’s Dance Studio or any related Miss Becky LLC activity. I agree to waive any and all claims I may have arising out of, connected with, or in any way associated with the activities of Miss Becky’s Dance Studio. I do hereby fully release and discharge Miss Becky’s Dance Studio, Miss Becky LLC, its owners, employees, assistants, volunteers, and instructors from any and all claims from injuries, damage, or loss which I or my minor child may have or which may occur as a result of participation in Miss Becky’s Dance Studio activities.Electronic Signature(Required) Date(Required) Referral and Registration Information(If New) I was referred to the studio by: *$25 Annual Registration Due for all Technique/Semester Class with Registration. Register by 9/1 and you can take $10 off your registration fee. 1st month’s Payment or Semester Payment also due at time of Registration. *Register for a specialty class by 9/1 and you can take $5 off. * You will receive a confirmation and receipt when your class has met the minimum requirement. If you would like to pay by credit card there is a $3 transaction fee.