Registration Form

Student Name:________________________________________________________________

Home Phone #:_____________________________Work/Cell #:____________________

E-mail Address:______________________________________________________________

Street Address:______________________________________________________________

City:___________________________State:__________   Zip:______________

IN CASE OF EMERGENCY, CONTACT:

Name:____________________________________   Phone #:_________________________

Please note any physical limitations, allergies, etc., that may affect participation:

Please write down any prior dance experience/dance interests:

How did you find out about this program?

PLEASE READ AND SIGN BELOW

I, the undersigned, understand that there are physical risks associated with dance or exercise of any kind. I declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in these classes, workshops, and activities offered by Hip Expressions LLC, and staff.  I agree that by participating in the programs and activities offered by Hip Expressions LLC, including classes, workshops and other activities, I expressly assume all risks and full responsibility for any injuries, damages, or losses which I may incur as a result from these activities, and I do hereby fully forever release and discharge Hip Expressions LLC, and its staff, partners, employees, and agents, from any and all claims, demands, damages, rights or actions or causes of action, present or future, whether the same be known or unknown, anticipated or unanticipated, resulting from or arising out of my participation in the classes, workshops, or other activities. 

I also grant Hip Expressions LLC the right to use any and all images taken of me at their events, classes, or shows, in any way they see fit to promote their programs.

Signature:__________________________________________         Date:_____________

Print Name: ________________________________________________________

(Please print name of signed & relationship, if student is under 18)

   FOR OFFICE USE ONLY

Event/Class:

Date: