Registration fee - $35 per student Pd. Registration ______

Pre-registration fee* - $30 per student Pd. Aug. Tuition ______

(*if paid before June 1, 2016) Total Paid $_____ Cash ___Check # ____

MARY ELLEN SCHOOL OF DANCE 2016-2017 Class Registration

3650 NE 25th Street Ocala, Florida 34470 352-732-2030

Registration Days – Returning Students - August 8th

New Students - August 9th

STUDENT INFORMATION:

Name ______Age _____ Date of Birth ______

Address ______City ______Zip code ______

Parents/Guardians ______

Email ______

Best phone number ______Who's phone? ______okay to text?__

Alternate phone ______Who's phone? ______okay to text? __

CIRCLE CLASSES INTERESTED IN TAKING: Musical Theater

Ballet Contemporary Turns/Leaps Flex/Core

Pointe Jazz Funk Tiny Tots (ballet/tap ages 3-5)

Lyrical Ballet/Jazz Combo Tiny Tumblers (ages 3-5)

Jazz Lyrical/Jazz combo Bumblebees (ages 1-2)

Tap Silks/Hoop Bumblebee Tumblers (ages 1-2)

Hip Hop Acrobatics Clogging

Acknowledgment, Waiver, Release

I/We, the undersigned parent(s)/guardian(s) voluntarily and knowingly execute this acknowledgment, waiver and release with the express intention of extinguishing obligations, claims, or causes of action as herein set forth.

I/We desire and have requested the services normally provided by Mary Ellen School of Dance, Inc., said services being in the form of dance instruction, dance classes, and related activities, in which I/we wish to enroll my/our child(ren), to be enrolled during the 2015-2016 dance instruction program year.

I/We acknowledge that I/We fully understand that there may be some risk of injury involved in the activities related to the dance instruction program. For and in consideration of the enrollment of my/our child(ren) in the aforementioned dance instruction program, and the providing of the aforesaid services by Mary Ellen School of Dance, Inc., I/We assume the risks involved and agree to be solely liable for and expressly release, discharge, and hold harmless the Mary Ellen School of Dance, Inc., its officers, directors, employees, appointees, agents or volunteers from any and all injuries, claims, or causes of action whatsoever resulting from or arising out of or during the above described dance instruction program and related services rendered by Mary Ellen School of Dance, Inc.

I/We acknowledge that Mary Ellen School of Dance has my permission to publish my child's photograph for use in the media or on the website to help promote the studio.

It is my/our intention that this release be binding upon my/our heirs, legal representatives and assigns, and that its coverage extend to the officers, directors, employees, appointees, agents and volunteers of the Mary Ellen School of Dance, Inc.,

Parent/Guardian: ______Date: ______