Broadway Bound Dance Center

2008 Summer Registration Form

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

Student’s Name:

Age: Date of Birth: Grade:

Address:

City: State: Zip:

Emergency Contact: Relation:

Emergency Phone Number: Medical Information:

Parent #1: Phones: (H) (C/W)

Parent #2: Phones: (H) (C/W)

Family e-mail: Student e-mail:

Discounted Packages (Please circle):

Half Day Packages (4-6 yrs.) Platinum Gold Silver

8 weeks 5 weeks 3 weeks

Full Day Packages (7+ yrs.) Platinum Gold Silver

8 weeks 5 weeks 3 weeks

Please write the theme of the dance week(s) you are attending, dates & costs:

Theme: _______________________________ Week: ______________ Cost: __________

Total Cost: _________

Please make checks payable to Broadway Bound Dance Center

I, the undersigned Parent or Guardian of the above student, release BROADWAY BOUND DANCE CENTER, including instructors and assistants, from any and all injuries which 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 for the above student incurred due to injury including, but not limited to, emergency medical transportation and treatment if the need arises. I also give my permission for the public display of any studio pictures that my child may be in.

Print Name:________________________________ Signature:____________________________ Date:________