REMEMBER…Class size is limited so register early!!!
West Roxbury School Of Dance
Registration and Release Form
- Student Name ____________________________________________Age_________
- Address __________________________Town Zip Code __________
- Phone Number ______________________________
- Cell Phone Number
- Student’s School _______________________ School Dismissal Time _________
- New Student or Returning Student (Please circle one)
When selecting classes, refer to the current schedule. Some changes have been made from the previous year. Also, please select an alternate class in case your first choice is unavailable.
A tuition payment of $190 is required at registration. A $10 is a non-refundable registration fee is included. Register early to ensure your desired placement, as classes fill up quickly.
I, __________________________________, of, _______________________________,
Massachusetts, individually and as parents of___________________________________,
a minor under the age of eighteen (18) years, in consideration for the opportunity afforded to my child at “West Roxbury School of Dance,” offered at Corey St. in West Roxbury, Massachusetts 02132, hereby agree and consent to release and forever acquit Emily Kingsbury, Dance Instructor, dba as West Roxbury School of Dance, from any and all claims or liability for damages for any occurrence in connection with the dance and exercise classes, which may result in injury or other damages sustained by my child while participating in classes or otherwise at “West Roxbury School of Dance.” In further consideration of the opportunity afforded to my child to participate in this instruction, I hereby personally assume all risks in connection with the said course. I have fully informed myself of the contents of this registration form and release by reading it before I sign it. My child is physically fit to participate in this course and I am not aware of any injuries or illness, which would limit such participation.
Parent/Guardian Signature: ____________________________________ Date:_____________, 2017.
Please list any Medical problems your child may have:
Please mail payment to: Make checks payable to:
Emily Kingsbury West Roxbury School of Dance or WRSD
1941 Washington St.
Canton, Ma. 02021
*We require a nine-month commitment from September to May*