ON LINE REGISTRATION FORM

-PLease Fill OUt Information Below-

Dancers Name *

Dancers Name

First Name

Last Name

Parent Name *

Email Address *

Address *

Please list house number, street, city, state and zip code.

Dancers Date Of Birth *

Parent Phone Number *

Alternate Phone Number

Health Concerns, Medications or Allergies *

Please list any health concerns, medical conditions or allergies that your child may have.

Emergency Contact Name *

Emergency Contact Phone Number *

Waiver (Initial Please) *

I release The MAC Dance LLC, it’s instructors, independent contractors, and all other associates from liability for harm, theft, or injury that may be suffered by me and/or member of my family traveling to or from or during participation in, activities and programs sponsored by The MAC Dance LLC. I hereby acknowledge that I am voluntarily assuming full responsibility for all risks of physical injury arising out of active participation in a dance class or other dance related activities. I understand that there are NO refunds for registration fees, costume, recital fees or classes. I understand and agree to The MAC Dance LLC policies and procedures. I give The MAC Dance LLC permission to use my child’s costumes/accessories until they are no longer needed for the season. I understand that my student must have this release form signed before attending class. I give permission to The MAC Dance LLC to use pictures and or video of my child for advertising purposes in print, promotional videos and on the website. Tuition is to be paid by the 7th of the month or a $10 late fee will be added, this fee increases to $15 after two weeks. If a payment is 30 days overdue then a fee totaling $25 will be applied to the account. If a payment is not received in a period of 4 months then the account must be handed over to a collection agency. I understand that I will be charged a convenience fee for all my credit card/debit card transactions at MAC Dance. This fee will apply each time I used my credit or debit card.

Class Name *

Please list class name in the space provided (ie Creative Dance 1 )

Class Day & Time *

Please list the day and time of your selection (ie Tuesday 4:00-5:00pm)

The education that we give will be of the highest quality, we provide a safe atmosphere filled with love and encouragement.