STUDENT REGISTRATION FORM 2025-2026

Student #1:

Student #2:

Student #3:

Parents’ Contact Information

Parent | Guardian Name:

Address

Cell Phone #

Emergency Contact Information

Name:

Relationship:

Cell Phone #

Medical History

Please List All Medical Conditions/Allergies:

How Did You Hear About Us:

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Student's Registration Information

Student #1

Student Name

Birthday

Cell Phone #

Description of Class Style | Day & Time | Hours

Student #2

Student Name

Birthday

Cell Phone #

Description of Class Style | Day & Time | Hours

Student #3

Student Name

Birthday

Cell Phone #

Description of Class Style | Day & Time | Hours

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Registration Fees are non-refundable: $50 Student; $65 Family of 2; $80 family of 3 plus (note: all must be residing in the same residence)

Registration Fees:

Tuition Student #1:

Tuition Student #2:

Tuition Student #3:

Costume Fees Student #1:

Costume Fees Student #2:

Costume Fees Student #3:

Total Tuition & Fees:

Please Select a Payment Plan:

Payment Plan 1: 2 Installments due August 1st and January 1st.

Payment Plan 2: 3 Installments due August 1st, November 1st, February 1st.

Payment Plan 3: 11 Installments due the 1st of each month for the months of August - June.

I authorize IPSOD to charge my credit card according to the payment plan selected above.

Credit Card

Master Card

Visa

Discover

Account Number:

Expiration Date:

Security Code:

Name on Card

Signature and Date

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If paying by check, make payable to Inez Patricia School of Dance. Returned check fee is $25.00.

WAIVER OF LIABILITY, RELEASE,

ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

I affirm that I am 18 years of age or older and mentally competent to enter into this Waiver, Release, Assumption of Risk, and Indemnity on behalf of

(Insert name if 18 or older or insert name of minor child under 18)

who is voluntarily participating in one or more instructional dance sessions or other events offered at Inez Patricia School of Dance (hereafter referred to as IPSOD).

I am not aware of any medical conditions I/my minor child have which may preclude me/my minor child from participating in dance activities. I understand there is a risk of injury associated with dancing and that such injuries may be caused in whole or in part by my minor child, or by the actions or inactions of other students or instructors.

In consideration of my/my minor child’s participation in dance instruction by IPSOD, and in further consideration of the expertise and achievements of Instructors at IPSOD, I/my minor child and I agree to all the following, which shall bind my minor child and myself.

Initials

A. I agree, or I agree to instruct my child to immediately stop performing any activity if I/my minor child feel any pain, dizziness, light headedness or any other symptoms, and to immediately report those symptoms to the instructor.

I also agree or to instruct my minor child to carefully follow the instructors’ directions, to ask for additional directions if I/my minor child does not understand any activity and to immediately stop any activity which I/my minor child is not competent or confident enough to perform.

B. To the fullest extent permitted by law, I agree and represent that I/my minor child and I assume the risk and responsibility for any and all injuries to myself/my minor child that I/my minor child sustains while performing any dance, Pilates or strengthening activities, including any and all costs and damages that are a consequence of such injuries, and whether such injuries costs and damages were caused in whole or in part by IPSOD, instructors, students or employees.

C. To the fullest extent permitted by law, I/my minor child and I agree to defend, indemnify and hold harmless IPSOD and their instructors, agents, employees, contractors, clients and students, from and against all claims, costs, damages, losses and expenses, including but not limited to attorney’s fees,

arising out of or resulting from myself/my minor child’s performance or other participation in any dance, Pilates or strengthening activities, regardless of whether or not such claim, cost, damage, loss or expense was caused in part by a party indemnified hereunder.

I have read, understand, and fully agree to the terms of this

WAIVER OF LIABILITY, RELEASE, ASSUMPTION OF RISK and INDEMNITY.

SIGNATURE OR SIGNATURE OF PARENT/GUARDIAN IF A MINOR

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Signature and Date

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LIMITED USE PHOTOGRAPHIC RELEASE

For and in consideration of my or my minor child engagement as a student by the Inez Patricia School of Dance (hereafter referred to as IPSOD) on terms hereinafter states, I or on my minor child’s behalf hereby give the Photographer/Videographer and IPSOD, their legal representatives and assigns, those for whom the Photographer/ Videographer and IPSOD are acting, and those acting with their permission, the right to copyright and/or use, reuse and/or publish, and republish the photographic pictures/film of me or of my minor child taken during the course of my study at IPSOD or at any school performances. I hereby waive any right to inspect or approve the finished photograph(s)/video(s) prior to publication. I hereby release, discharge, and agree to hold harmless the Photographer/Videographer and IPSOD, their representatives, assigns or any other person or persons, corporation or corporations, for whom they might be acting, including any firm publishing and/or distributing the finished product, in whole or in part, from and against any liability as a result of its publication or distribution of the same. I certify that I am suffering under no legal disabilities and that I have read and foregoing release, authorization, and agreement, before affixing my signature below, and warranty that I fully understand the contents thereof.

SIGNATURE OR SIGNATURE OF PARENT/GUARDIAN IF A MINOR

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Signature and Date

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4690 Hoffner Ave, Orlando,

FL 32812, USA

407-730-5177

info@inezpatriciadance.com

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