Broadway Bound Dance Center

Adult/Teen 2010 Registration Form

Mail to: Broadway Bound Dance Center, 17 Willow Street, Natick, MA 01760

Name:
Address:
City:	State:	Zip:
Phone (Home):	(Cell):
Email (Home):	Email (Work):

 

Emergency Contact:	Relation:
Emergency Phone Number:
Medical Information:

 

 

Check all that apply:

            ____ $96 for Session 3 of Modern, Tuesdays, 7:30-8:30pm (Feb. 2nd – March 30th)

            ____ $96 for Session 3 of Hip Hop, Thursdays, 7:30-8:30pm (Jan. 28^th – March 25^th)

            ____ $96 for Session 3 of Tap, Thursdays, 8:30-9:30pm, (Jan. 28^th – March 25^th)

________________________________________________________________________________

 

I, the undersigned student, release BROADWAY BOUND DANCE CENTER, including instructors and assistants, from any and all injuries that may occur from training, practicing, performing and/or during any event or activity.  I also agree that I am responsible for the health and accident insurance and any medical costs uncured due to injury including, but not limited to, emergency medical transportation and treatment if the need arises. 

Print Name: _____________________ Signature: _______________________ Date: ________