impact performing arts

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2019 Fall Registration Form

Dancer's First and Last Name *

Dancer D.O.B *

YYYY

Parent/Guardian First and Last Name *

Parent/Guardian Email *

Cell Phone Number *

School Attending *

Fall 2019 Grade *

How Did You Hear About Impact? *

Any Injuries or Illnesses? *

Class Selections

Please list class(es) below.
Payment is due in FULL on or before the first class. Class fees are non-refundable.
Additional $150 for Poms, Int Ballet, Adv. Modern, Adv. Jazz & Adv. Pointe/Ballet.
25% Sibling Discount on dance class fees ONLY.
NO Sibling Discount for DanceWorx Company Members

#1 Day/Time/Class/Teacher *

#2 Day/Time/Class/Teacher

#3 Day/Time/Class/Teacher

#4 Day/Time/Class/Teacher

#5 Day/Time/Class/Teacher

Wavier

Participation in any Impact Performing Arts activity on or off site, and use of recreational facilities involves risk of accidental injury despite all safety precautions. Having been informed of the activities conducted by Impact Performing Arts, I/we, as individual or as a parent or guardian of the participants named herein, assume all risks and hazards incidental to the activities, and release from responsibility and agree to indemnify and hold harmless Impact Performing Arts, its officers, directors, independent contractors, volunteers and all employees for any illness or injury to me or my child or family members accruing during his/her/our participation in any activity or use of any recreational facility at or conducted by Impact Performing Arts. I also agree to the use of my child’s photo/video for Impact Promotional purposes.

Printing name below will serve as your signature.

I agree to the wavier above. Parent/Guardian (Print Name) *

Payment Options *

I want to pay online. Please send me an email invoice.

I will bring in a check, cash or credit card the first day of class.

Questions

Please call or email with any questions or concerns. (240)-340-1635 or info@impackpak.com

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