CENTRE FOR DANCE, DRAMA & MUSIC
Port Richey Dance Time – “Expressions”- THE dance company Inc. ,  
Spangles – dancewear.

6464 Ridgewood Square
Port Richey, FL  34668                                                                          Payment:   Enrollment-

  TEL# 727-842-8175  or 727-967-8225                                                                                 Fees   -

E-MAIL ADDRESS :  Gillian@portricheydance.com                                Dancewear  -

                                                                                                                          TOTAL=

STUDENT INFORMATION:

STUDENT’S NAME …………………............……………AGE….....….

ADDRESS …………………….........………CITY …..............……. ZIP………………

TELEPHONE#: HOME………......……….WORK:…......……………………..

EMERGENCY TEL#…….....……………...FAX #………….....………………

E MAIL ADDRESS :………………………………………………………

DATE OF BIRTH…............…………

 MOTHER’S NAME:…….......………………OCCUPATION….....…………….

 FATHER’S NAME………….....……………OCCUPATION......………………

 CLASSES …………………………# OF CLASSES PER WEEK……….

 

REGISTRATION FEE:
AN ANNUAL FEE OF $20 PLUS AN ADDITIONAL $5 FOR EACH OTHER FAMILY MEMEBER.  
A REGISTRATION IS NOT CONSIDERED COMPLETE AND CLASS SPACE WILL NOT
 BE RESERVED UNLESS THIS FEE IS PAID.

INSURANCE:
PORT RICHEY DANCE TIME CARRIES LIABILITY INSURANCE FOR ITS STUDENTS
 IN ACCORDANCE WITH COUNTY LICENSING REGULATIONS.  THERE IS A $5 FEE
 PER STUDENT FOR THE FULL DANCE YEAR.  HOWEVER YOUR OWN FAMILY MEDICAL
 INSURANCE SHOULD COVER YOUR CHILD IN THE EVENT OF INJURY AND BE YOUR
 SOURCE OF REIMBURSEMENT                  

ACKNOWLEDGMENT OF RISK AND WAIVER OF LIABILITY.

 

AS LEGAL GUARDIAN OF____________________________  ,I HEREBY CONSENT
 TO THE AFOREMENTIONED PERSONS PARTICIPATING IN THE PORT RICHEY DANCE TIME
 PROGRAMS. I RECOGNIZE THAT ACCIDENTS CAN OCCUR IN ANY ACTIVITY INVOLVING DANCE,
 GYMNASTICS AND RELATED ACTIVITIES.

I UNDERSTAND THAT IT IS THE EXPRESS INTENT OF PORT RICHEY DANCE TIME TO PROVIDE FOR
 THE SAFETY AND PROTECTION OF MY CHILD AND, IN CONSIDERATION FOR ALLOWING MY CHILD TO
 USE THE FACILITIES, I HEREBY RELEASE THE PORT RICHEY DANCE TIME, ITS OFFICERS, 
EMPLOYEES, TEACHERS AND COACHES FROM ALL LIABILITY FOR ANY AND ALL DAMAGES AND 
INJURIES SUFFERED BY MY CHILD WHILST UNDER THE INSTRUCTION, SUPERVISION OR CONTROL
 OF THE PORT RICHEY DANCE TIME.

AS LEGAL GUARDIAN OF THE AFOREMENTIONED PERSON, I HEREBY AGREE TO INDIVIDUALLY
 PROVIDE FOR THE POSSIBLE FUTURE MEDICAL EXPENSES WHICH MAY BE INCURRED BY MY CHILD
 AS A RESULT OF ANY INJURY SUSTAINED WHILST TRAINING AT, OR PERFORMING FOR, THE
 PORT RICHEY DANCE TIME.

THIS ACKNOWLEDGMENT OF THE RISK AND WAVIER OF LIABILITY, HAVING BEEN READ 
THOROUGHLY AND UNDERSTOOD COMPLETELY, IS SIGNED VOLUNTARILY AS TO ITS
 CONTENT AND INTENT.

I AGREE TO BE FINANCIALLY RESPONSIBLE FOR REGISTRATION FEE, INSURANCE FEE, 
MONTHLY TUITION TO BE PAID AT SPECIFIED TIMES AND CHARGES FOR CHECKS RETURNED, 
FOR THE ABOVE STUDENT. I UNDERSTAND THAT THERE WILL BE NO REFUNDS GIVEN.

  _________________________________ ___                        _______________

SIGNATURE OF PARENT/GUARDIAN                                                        DATE

  IF YOU HAVE ANY QUESTIONS OR COMMENTS, PLEASE FEEL FREE TO DISCUSS IT
 WITH US WHENEVER IT DOES NOT INTERFERE WITH A CLASS. WE ARE ALWAYS
 INTERESTED IN IMPROVING OUR DANCE EDUCATION PROGRAMS.

I ACCEPT THE AFOREMENTIONED POLICIES OF THE PORT RICHEY DANCE TIME AND
 WILL ABIDE BY THE REGULATIONS STIPULATED.

  _____________________________________                       _________________

SIGNATURE OF PARENT/GUARDIAN                                                        DATE

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