Solestice Dance Academy Fall Registration 2023-24
Please complete a separate form for each student.
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Email *
Student First Name (and preferred name) *
Student Last Name *
Student DOB (MM/DD/YYYY) *
Parent/Guardian (first and last name) *
Street Address *
City *
State (abbreviation) *
Zip Code *
Primary Phone Number (xxx) xxx-xxxx *
Emergency Contact Person (first and last name) *
Emergency Contact Relationship (must be over 18) *
Emergency Contact Phone Number (xxx) xxx-xxxx *
Health/Medical Issues *
Disclosure Agreement: Participants assume all risks of injury arising out of participation in all Solestice Dance Academy's activities on the premises or within the community and use of it's equipment and for myself, instructors, heirs, and assigns hereby waive, release and agree to hold free from all claims for damages the associates, officers, directors, instructors or other participants. I understand the possible risks and dangers involved in participating in such programs and agree to all policies and procedures outlined in accordance with Solestice Dance Academy's policy. My electronic signature below indicates my agreement to all documented policies as well as permission to use any pictures or other media for promotional purposes.

Type first and last name of person completing this form
 *
I agree to pay the required registration fee of $15.00 via cash, check, or Venmo.
 *
A copy of your responses will be emailed to the address you provided.
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