Registration for Genie Dance Classes

Student Name ___________________________________ Age: ___

Birth Date: _____________

Student Name ___________________________________ Age: ___

Birth Date: _____________

Address:  ______________________________ City _____________

State ___ Zip ___________

Parent/Guardian’s Name: __________________________________

Hm. Ph. _____________________ Wk. Ph. _____________________

Parent’s Mailing Address: ___________________________________

Will anyone else be transporting child to class?  Yes ___ No ___

If so, name the person and the relation to the child:

_______________________________ Ph. _________________________

Enclosed is $ ________ for ____________________________

E-mail: _________________________________

SPECIAL NOTE: Miramar’s Danse Arabesque and gKFitness cannot assume any liability or responsibility for injuries incurred by you or others while you are taking classes, performing, or otherwise participating in these events.  Such activities are at your risk; and by agreeing to participate, you assume the risk, and responsibility for injuries.