Child's Name:___________________________ Age:________ DOB:__________

Parent's Name:____________________________________________________________

Parent's Phone #:_______________________________________________________________

Address:__________________________________________________________

_________________________________________________________________

1st Choice Class (Day/Time):

____________________________________________________

2nd Choice Class (Day/Time):

____________________________________________________

Parent Consent: Every effort will be made to create a safe environment. I release Dance Imagination from all liabilities for injuries or damages arising out of personal injury. We will charge a $25 fee for returned checks.

Parent's Signature:__________________________ Date:_______________

Email Address:_____________________________________________________________________