2187 Lexington Rd.

Bldg. B- Suite 3
Richmond, KY 40475
www.bluegrassdancecenter.com
(859) 625-9393

Youth Registration Form

One Form Per Student | Please Print

Parent #1 Name:

Address

City State Zip Code

Tel #1 Tel #2

Email:

Parent #2 Name:

Address

City State Zip Code

Tel #1 Tel #2

Email:

We will use email as a means to send information, reminders, etc. Please consider giving us your email address to help facilitate
better communication between the studio and your family.
Student’s Name: Birth Date: (M/D/YYYY)

Student’s age (as of 9/1) Grade (as of 9/1) Name of School

Emergency Contact Name: Emergency Contact Number:

Previous training? Please list past experience in dance (include styles of dance and number of years)

Name of previous dance school:

Any health or physical restrictions or conditions such as allergies?

How did you hear about our studio?

Notification of personal risk

Dance classes use varying levels of physical effort. We want participants and parents to be aware of the inherent risks to bodily
injury resulting from dance however, every precaution is taken to avoid injury.

Policy of personal property and valuables

Bluegrass Dance Center cannot be responsible for theft, loss or damage of personal property occurring in class. Please use
discretion when selecting personal items that you bring with you into the dance center.

Hold harmless agreement

I _____________________agree to hold harmless Bluegrass Dance Center, LLC, against any and all
(Parent Name)
injuries, cost, losses, damages and expenses (including attorney’s fees) which I or my child, ________________________might
suffer from participation in any class, production, rehearsal or event of
(Child Name)
whatever kind or character and without limitation. By signing this agreement I understand and I am waiving any claims, liens,
demands or causes of action, which I may now or in the future possess against Bluegrass Dance Center arising out of or in any way
related to my participation or my child(ren) in any class, production, rehearsal or event.

Printed NAME________________________SIGNATURE______________________________DATE___________