Children’s Fall 2023 Dance Class Registration Form

Participant's First Name^*

Participant's Last Name^*

Which class will your child be taking?^*

Saturday Pre-School 9:15
Saturday 10:00am JK/SK
Saturday 11:00 Grade 1/2/3

Participant's Age^*

Particpant's Date of Birth^*

Main Contact First Name^*

Main Contact Last Name^*

Main Contact Phone Number^*

Main Contact Email^*

Pick-up: Is there anyone besides yourself that is authorized to pick your child up after class?

Special Considerations: Is there is anything you would like me to know about your child that might affect his or her safety, or the safety of others, or that will enable your child to benefit more fully from this program?

Photo/Video Permission Form: Please indicate whether I have permission to photograph or videotape your child for my records only?^*

Yes, my child's participation maybe documented.
No thank-you, please don't make a record of my child's participation.

Acknowledgement of Risks:^*

“I am aware that the activity of dance training carries with it certain risks of injury. These types of injuries may be minor or serious and may result from one’s own actions, or the actions of others, or a combination of both.”

Waiver of Liability:^*

“I hereby agree to release and discharge Jessica Runge, or any substitute instructor of this class, the Intergalactic Arts Collective and its directors and members, and Artscape and its directors and members, from any and all claims for any injury to my child, or loss, damage, or expense that may arise as a result of my child’s participation in this program.”

Payment Method^*

I will be sending an e-transfer to jessica (at) jessicarunge.com to secure a spot on class

Classes are $175 for the September 23 - December 2 series of 10 classes.

Refund Policy^*

Payment cannot be refunded, unless it is due to an emergency.

Agreement to Terms^*

Please check here to confirm you have read and agree with the terms of enrollment.

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