United Rhythms Dance Studio Registration Form 2022-23

Student and Parent Info

Students Name *

Primary Email Address *

Parent/Guardian Names *

Address *

City *

State *

Zip *

Any health risks we should be aware of: *

Primary Phone Contact: Name and Number *

Student's Date of Birth * +

Emergency Contact: Name/Phone/Relation *

Additional Student Info

Student's Name *

Any health risks we should be aware of: *

Student's Date of Birth *

Classes Each Student is Registering For:
Please write Student Name (if multiple registering) along with Day/Time/Teacher *

Annual Registration Fee *

$30 Fee One Dancer Dancer

$40 Fee Family Registration

Payment Options: Tuition is due the first week of each month *

I will pay by Venmo @unitedrhtymsdance

I will pay by Credit Card. ( We will take your information at the studio for this option).

I will pay cash at the studio

I hereby grant United Rhythms and/or it’s faculty and staff permission to take, reproduce, and publish pictures and or videos of myself and/or my dancer.. I hereby grant permission to use the images of said likeness in any and all of United Rhythms publications including web based publications. Which includes, but is not limited to United Rhythnms Facebook page, and/or Instagram account. United Rhythms will be discreet and will strive to protect the privacy of all its students and faculty. Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19 I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at United Rhythms Dance Studio or participation in United Rhythms Dance Studio classes. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless United Rhythms Dance Studio, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of United Rhythms Dance Studio its employees, whether a COVID-19 infection occurs before, during, or after participation in any United Rhythms Dance Studio program, class or event. Signature of Parent/Guardian I agree to the terms and conditions *

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Parent/Guardian Name and Date *