Fall, 2019
Registration Fall, 2019

Student(s) Last Name ______________________ First ______________________

Birthday ______/______/______ Age _________ Grade ______________

Parent/Guardian  _____________________________________________________

Phone (H) __________________________ (W) _____________________________

E-mail _______________________________________________

Address ____________________________________________________________

City __________________________________ State _____________ Zip ________

Emergency Contact ___________________________Phone__________________

Health/Physical Limitations ____________________________________________

Physician __________________________________ Phone __________________

Class/Camp Title ______________________________  Tuition_________________
Day ______________________________________  Time_____________________

Class Title ___________________________________Tuition _________________
Day ______________________________________  Time ____________________

Class Title ___________________________________Tuition _________________
Day ______________________________________  Time ____________________

There is no registration fee.
Please make checks payable to: Children’s Dance Workshop and mail this form to:
Children’s Dance Workshop
427 North Hickory Road
South Bend, IN  46615-3562                                  Check enclosed for _______________

Every effort will be made to contact the parent in the event of a medical emergency.  If we are
unable to reach the parent or guardian, your signature below authorizes Bonnie Boilini Baxter
to seek medial treatment for your child.  The parent/guardian accepts full financial
responsibility for said care.  I hereby waive for myself, my child, heirs, issues and assigns all
claims of liability against Bonnie Boilini Baxter, the Children’s Dance Workshop, their
instructors, employees, heirs and assigns.

X _____________________________________ Date_________________________