2023 ONLINE REGISTRATION FORM

Student's Full Name

Student's Age & Birth Date

Student's Home Address (Address, City, State, Zip Code)

Mother's Name

Mother's Home Phone & Cell Phone

Father's Name

Father's Home Phone & Cell Phone

Marital Status

**If divorced, the names of both parties must be entered in the Hold Harmless Agreement section.

Married

Divorced**

Single

Preferred Email Address

Secondary Email Address

Is your child a new student?

What does his/her prior dance experience include?

We were referred by:

How did you hear about Paula Scriva Dance Studio?

Hold Harmless Agreement – Understanding that it is the purpose of the Paula Scriva Dance Studio Inc. to provide supervised instructions for boys and girls, I, the parent or legal guardian of the above named, do hereby give my approval to his or her participation in any and all the activities during the current season. I do recognize and assume all the risks and hazards incidental to the conduct of the indemnify and hold harmless Paula Scriva Dance Studio, the organizers, sponsors, and the supervisors, any or all of them, in case of injury to the above named candidate. I hereby waive all claims against the organizers, the sponsor, or any of the supervisors or instructors appointed by them in their efforts to attain proper medical attention.

I have read the above and understand and agree.

Please enter the names of agreeing parents/guardians here.

2023 ONLINE REGISTRATION FORM

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