Fairytales in Motion
Registration
Winter/Spring 2012
Classes and Holiday Camp
Student’s Name_________________________
Age_____Sex____Child’s Date of Birth__________________
Parent’s Name____________________
Home Phone______________________
Business Phone____________________
Address__________________________
City______________St____Zip_______
Email Address_____________________________
Class/Camp Code:
1st choice______2nd choice_______
I, ___________________________________
have enrolled my child __________________
in a program of physical activity including but not limited to creative movement and or Ballet/Jazz.
I hereby affirm that my child is in good physical condition and does not suffer from any disability that would prevent or limit his/her participation in this program.
In consideration of my child’s participation in Fairy Tales in Motion, I ______________________________
for my child, myself, my heirs and assigns release Fairy Tales in Motion (it’s (and it’s members and owners) from any claims, demands and causes of action resulting from any participation in the dance program.
____________________________________
Parent or guardian’s signature and date
Please mail this form along with check for payment in full to:
Jan Taylor
P.O. Box 51
Brookeville, MD 20833-0051
301-253-0484
