Registration & ConsentPlease complete the form below to complete your registration. Name of person filling out form(Required) First Last May we thank someone for referring you?(Required) Yes No Name of person that referred you If you have children, what school do they attend?(Required) Write N/A if this does not apply.Student InformationInclude yourself as Student #1 if you are taking or plan on taking any classes.Student #1 Name(Required) First Last Student #1 Date of Birth(Required) MM slash DD slash YYYY Student #2 Name First Last Student #2 Date of Birth MM slash DD slash YYYY Student #3 Name First Last Student #3 Date of Birth MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Main Contact Phone Number(Required)Main Contact Email(Required) Emergency Contact Name(Required) First Last Emergency Contact Phone Number(Required)Emergency Contact Relationship(Required) Additional Emergency Contact Name First Last Additional Emergency Contact Phone NumberAdditional Emergency Contact Relationship Medical InformationPlease list any medical conditions or information that Moovment House LLC needs to be aware of to ensure your safety, if applicable:Waiver & ReleasesPhoto Release(Required) I agreeI give full consent to Moovment House, Between the Bones, LLC to use all photographs or videos in which I may appear. I further agree that Moovment House, Between the Bones, LLC may use all photographs or videos in exhibitions, public displays, publications, and for advertising purposes.Signature(Required)Date MM slash DD slash YYYY Liability Agreement/Medical Release(Required) I acknowledgeI understand the risks of physical injury in dance training (whether joining online classes or in person classes) and am willing to take those risks. I understand that Moovment House, Between the Bones, LLC will take the utmost care in providing a safe environment for learning and dance. Therefore, I will not hold Moovment House, Between the Bones, LLC or any teacher or staff member liable for injury or illness while participating in this program. I understand that it is my responsibility to safeguard any personal property and understand that it is not the responsibility of Moovment House, Between the Bones, LLC or the Sixth Avenue United Church of Christ to safeguard against loss or theft. In case of emergency, I give permission to Moovment House, Between the Bones, LLC to take the necessary precautions for injury and illness and to provide necessary transportation to a medical doctor or hospital where treatment may be received by a licensed physician if necessary.Signature(Required)Date MM slash DD slash YYYY
