Music School Registration Form 2007-2008

                                                                                                                                       

_______________________________________________________HOME PHONE (515) ___________________

LAST NAME (OF STUDENT HOUSEHOLD)            

 

CELL PHONE #’S______________________________________________________________________________________

 

HOME ADDRESS_______________________________________  CITY__________________________ ZIP_____________

 

Mother’s Name_________________________  Work Phone______________________ Employer_______________________

 

Father’s Name_________________________  Work Phone______________________ Employer_______________________

 

E-mail address (Newsletter will be sent monthly) ______________________________________________________________

 

Person(s) responsible for payment, if different from above_______________________________________________________

 

Student  #1           

 

__________________________________________________________________(___)_____/___/______________________

LAST NAME                              FIRST NAME (they want to go by)                      AGE         Birthdate           Grade (fall 2007)

        

Student  #2   

 

__________________________________________________________________(___)______/____/___________________

LAST NAME                              FIRST NAME (they want to go by)                       AGE         Birthdate          Grade (fall 2007) 

                      

Student   # 3    

 

__________________________________________________________________(___)_____/_____/__________________

LAST NAME                              FIRST NAME (they want to go by)                       AGE           Birthdate        Grade (fall 2007)                           

                                                               

 

Lesson type you are interested in taking?  _____________________________

 (if more than one child please put their name by the class they want to take)

2007-2008  Release Statement

 

PART 1:  Release to allow Superstars to Render First Aid and/or seek Emergency Services in the absence of Parents or Guardians

     I fully understand that Superstars staff members are not physicians or medical practitioners of any kind.  With the above in mind,
I hereby release the  Superstars staff to render temporary first aid to my child or children in the event of any injury or illness,
and if deemed necessary by the  Superstars staff to call our doctor and seek medical help, including transportation by Superstars
staff member and or its representatives, whether paid or volunteer, to any health care facility or hospital, or the calling of an ambulance
for said child should the Superstars staff deem this to be necessary.

PART 2:  Agreement not to sue or cause litigation versus Superstars. its agents or employees

     With the above in mind, and being fully aware of the risks and possibility of injury involved, I consent to have my child or
children participate in the programs offered by Superstars and or its representatives whether paid or volunteer.

     I also affirm that I now have and will continue to provide proper hospitalization, health and accident insurance coverage which
I consider adequate for both my child’s protection and my own protection.

     I also give my permission to Superstars staff to give my child (ages 11 and older) Tylenol or ibuprofen if deemed necessary. 

PART 3:   I have read the policies, fees and payment plans. I agree to follow the rules as stated in the policies of the Superstars Baton, Dance & Gymnastics Center.
If I fail to follow the rules as stated I know that my child will be dropped from classes.   I agree to make the payments required for my child(ren) to participate in the classes
he/she/they are registered and all other fees and merchandise involved.   I also agree to pay any late fees outlined in these policies, legal fees, mediation or court costs
if the Superstars have to pursue payment of my account.   

 

X _____________________________      ___________________

                                             Parent or Guardian Signature                                                                                       Date

 

 

 EMERGENCY CONTACT INFORMATION

 

Student name(s)_________________ __________________________           

 

In case of an emergency and the parent cannot be reached we need another person(s) to contact for your child.
In case of a medical emergency the person should live in or close to your community.

 

Parents cell phone numbers ____________________________________________________

 

Name ________________________________________   Phone ___________________    Relationship_______________

 

Name ________________________________________   Phone ___________________    Relationship_______________

 

Doctor ____________________________Hospital___________________________________ Is there any medical information we would
need to give to medical personnel in case your child would not be able to speak? (i.e.: allergies, medications,etc)