KHARISMA DANCE STUDIO

ON-LINE REGISTRATION FORM

(Please complete and submit this form before attending your first class)

Student's Name *
Student's Name
Local Address *
Local Address
Home Phone
Home Phone
Mobile Phone *
Mobile Phone
Birthdate
Birthdate
Emergency Contact's Name
Emergency Contact's Name
Home Phone *
Home Phone
Mobile Phone *
Mobile Phone
Work Phone *
Work Phone
Please provide in the space below any health problems or conditions of which the studio should be aware (such as heart, back, medical, allergy, muscular, pregnancy, diabetes, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc.). I understand that risk of injury is inherent in any physical activity and I knowingly and voluntarily accept that risk. I, the undersigned, for myself, my heirs, administrators, and executors, hereby waive and release Venae Sears individually and Kharisma Dance Studio and its staff from any and all claims or damages of any kind arising out of my participation in the exercise and/or dance program of Kharisma Dance Studio. I certify that I am in proper physical condition to participate in the exercise/dance program and that I have been examined by a licensed physician and found to be in proper physical condition to participate in said program. I, the undersigned, do hereby authorize Venae Sears or her designated agents (being teachers or administrators employed by Kharisma Dance Studio) to obtain medical treatment for myself in emergency situations, if needed. I understand that I am responsible for any medical expenses and that the absence of health insurance does not make Kharisma Dance Studio responsible for payment of medical expenses. This authority includes the power to authorize any and all treatment deemed necessary under the circumstances by a licensed physician. This power is in essence a power of attorney and shall remain in effect for one year from the date this form is submitted.