PSB DANCE ACADEMY

2014 2015 REGISTRATION FORM

Name of Student: ____________________________________________Date of Birth: ___________ ____
Month/Day/Year

Age

Mothers Name: ______________________________Fathers Name: _____________________________

Address: ______________________________________________________________________________
Street

Unit

City

Postal Code

Phone (H): ____________________________ email: _____________________________________

Phone (Cell) Mother: ________________________ Phone (Cell) Father: ________________________
Name of Doctor: _______________________________________Phone: ___________________________
Health Card Number: ____________________________Allergies/Medical Condition: ________________
Emergency Name: _________________________________________ Phone: _______________________
Relation to Student: _______________________________
Where did you hear about the school?
Newspaper(which?)_______________________ Camp Guides ________ Internet_____________
Dance Magazine_________ School Location Sign___________ Return Student______________
Referral (by who?)___________________ Other (please specify)__________________________
CLASSES SELECTED:
*All post dated cheques or automatic withdrawal from charge card authorization must accompany application
*A charge card is required at time of enrollment. Outstanding fees will be charged to charge card at net 30 days.
* Please do not forget to enclose a separate cheque for the $30.00 registration fee..
* Performance rental of $85.00/costume fee of $130.00 is due on enrollment date, includes a DVD one per student
* Please read all rules, regulations and release form prior to signing and dating form
* 13% taxes are applicable on all fees.

PROGRAM CHOICE:
Recreational_____ Intensive_____ Enhanced______ Profile Dance Co.______ Competitive______
Name of Class/Day/Time:
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
*Use another form, if you run out of room

Name of Class/Day/Time:
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________

NAME of PARENT or GUARDIAN _______________________________________________________

PROGRAM RULES ACCEPTANCE SIGNATURE _________________________________________
Office Use Only
Date of Enrollment__________________________ Start Date__________________________________
Total Hrs/Week________ Fee Per Term(before HST): _________Fee Per Month(before HST): _________
Reg Fee Paid ($30.00 + HST) ________

Discounts given: Early Reg: ______

5% sibling ___________

Jr. PDC Costume Fee ($265.49+HST) ________Sr. PDC Costume Fee ($353.99+HST)_______________
Competitive Costume Fee ($177.00+HST) ______________
Performance Fee x ____# of rentals x $85.00 =_________(+ HST) Dance form _____________________
Costume Fee x ____# of costumes x $130=__ __________(+ HST) Dance form _____________________
Payment Method:
Post-dated Term (incl HST): 4 cheques _____________ Post-dated Monthly*(incl HST) _____________
Full Payment (incl HST) _________________
*NOTE: Post-dated Monthly cheques 10 months, First and last payment made at time of registration
SIGNATURE of ACCEPTANCE of PAYMENTS ___________________________________________
Charge Card Monthly Withdrawal ____________ Charge Card: Amex, M/C, VISA (circle one)
Term payment ___________ Monthly payment ___________ Full Payment _________ (please initial one)
Charge Card # ________________________________ Expiry date_____________ Verification code_____
Card Holder Name _______________________Signature Authorization: ___________________________

RELEASE AND INDEMNIFICATION

Name of Student: _______________________________________________________________________

Name of Parent/Guardian (If Student under 18 years of age): ____________________________________
Date of Registration: ______________________
Course Location:
PSB 1 - 91 Rylander Blvd, Scarborough, ON, M1B 5M5 ____________
PSB 2 - 2351 Kingston Rd, Scarborough, ON, M1N 1V1 ____________

RELEASE AND WAIVER

In consideration of PSB Dance Academy, accepting this application, I, for myself, my heirs, executors,
administrators and assigns, release PSB Dance Academy, its respective servants, agents and employees
from any claims, demands, damages, actions or causes of actions whatsoever arising out of or in
consequence of the above-noted Student participating in a dancing lesson/course or any other activity
related to PSB Dance Academy including but not limited to claims, demands, actions or causes of actions
related to loss of or damage may have arisen by reason of negligence of PSB Dance Academy, its servants,
agents or employees. Without limiting the generality of the foregoing, I further release any recourses
which I may now or hereafter have resulting from any decisions or activities of the PSB Dance Academy.
For the aforesaid consideration I agree to indemnify PSB Dance Academy, it servants, agents or employees
from any claims or demands which might be made against the PSB Dance Academy, arising out of or in
consequence of the attendance or participation by the Student in a dance lesson/course or any other activity
of PSB Dance Academy. If this Release and Waiver is signed by any person other than the Student, the
Student is under the age of eighteen (18) years, and I have full legal right and authority to sign this waiver
on behalf of the Student.
_______________________________________
(Signature of Parent or guardian, if student less
than eighteen years of age)

_________________________________________
(Signature of Student, if eighteen years of age or
older)

Regulations and Dress Code at PSB

I have received a copy of the Regulation guidelines and dress code of PSB and have read it thoroughly
prior to signing this form. I will also go through these guidelines with my child so that he/she is aware
prior to class participation.
__________________________________
Date

_________________________________
Date

__________________________________
Parent/Guardian Signature

_________________________________
Students signature (18 and over)

__________________________________
PSB Staff Signature
I give permission for PSB to use photographs of my child ______________________for promotional
purposes only.
Yes _________________________ Signature of Parent/Guardian

No ______________________

Please note that if any part of the registration form is incomplete or post dated cheques or correct charge
card information are not attached, your child will not be registered in the class.
Please make sure all information is filled in correctly and changes may not be permitted on this form.