REGISTRATION FORM

Name *
Name
Parent Name *
Parent Name
Address *
Address
Registering for: *
(Please check each class you wish to register this student for.)
Annual Registration Fee and Class Deposit due at time of registration. CLASS DEPOSIT: $50 PER CLASS. Deposit is non-refundable and is applied to the fourth quarter tuition payment. ANNUAL REGISTRATION FEE: $35 per family. Invoices will be sent by email from LBG Bookkeeping Services at lbgbook@verizon.net Payment options: Online Payment Network, cash, or check. You may pay in full at any time. Invoice Payment Due Dates: September 15, 2017, November 15, 2017, January 15, 2018, and March 15, 2018. *
I understand that in the event my child/minor cannot or chooses not to continue participation in a class or classes at IMC, I am responsible for full payment of the total tuition of the class or classes we have committed to within 60 days of termination. In addition, if my child/minor is asked to terminate participation due to unacceptable conduct, I am responsible for full payment of the total tuition of the class or classes we have committed to within 60 days of termination. I understand that neither The Ipswich Dance Foundation, nor its affiliates (of which Ipswich Moving Company is one), employees, agents and representatives are liable for personal injuries or loss to personal property. I understand that due to the physical nature of these activities injuries may occur. I understand that each student (or their guardian) is responsible for disclosing physical or other limitations prior to participation in any activity. In addition I understand that Ipswich Moving Company School of Dance will have the opportunity to have photographs taken of it’s participants for promotional purposes and I give my permission for myself (if 21 years of age) or my child to be photographed for that purpose only. I release all claims against Ipswich Moving Company with respect to copyright ownership and publication. *
Signature and Date
Date of Signature *
Date of Signature
Medical Information
EMERGENCY CONTACTS: In case of emergency parents/guardians will be contacted first. Please list two additional emergency contact names below (in case parents/guardians are unreachable).