Davis Center Application Packet

APPLICATION FOR ENROLLMENT STUDENT’S

NAME___________________________________________________ STUDENT’S DOB _______________

ADDRESS (No. Street)__________________________________________________________________________

CITY ________________________________________STATE_________ZIP CODE__________________

HOME PHONE____________________________WORK/ EMERGENCYPHONE_________________________

E-MAIL ADDRESS_________________________________________CELL PHONE_______________________

FOR STUDENTS UNDER AGE 18:

PARENT’S NAME__________________________________________________________

PREVIOUS DANCE TRAINING: None______ Slight_____ 2 or more years_______ 6 or more years________

New Student (to t he Dav is Cente r)____ Returning Student, last enrolled? ________

CONSENT & RELEASE: I am the participant listed above, or parent/custodian of the child listed above, and hereby agree to participate, or consent to my child’s participation, in the dance and exercise course(s) given by t he Davis Center , its officers, directors, employees, faculty and agents (therein collectively called the Davis Ce nter with the understanding and condition that I am in possession of a valid brochure and current schedule. I certify that I/my child am/is in good health and is capable of participating in all School activities and classes. I hereby give permission for t he Da vis Center to take and use photographs for promotion purposes for the SCHOOL.I fully understand that there are no refunds or credits of registration fees, tuition payments, classes, costume fees or any other fees regardless of the circumstances. I understand that I am responsible for tuition payments as described. I thereby release the Davis Ce nter , it’s agents and employees, from all liability for personal injury, illness, or property damage occurring on or off t he Davis Center's premises, whether or not caused by the negligence of t he Davis Ce nter, it’s agents or employees. I further release the Trinity Episcopal Church and its employees, officers and agents from all liability for personal injury, illness, death or property damage occurring on the premises, except as caused by the gross negligence of Trinity Episcopal Church or its employees, officers and agents. I hereby execute and deliver this Consent and Release to induce t he Davis Ce nter to permit to participate in its programs. In the event any provision of this Consent & Release is held to be invalid or unenforceable, this Consent & Release shall be construed as if such invalid or unenforceable provision is not contained herein. IN WITNESS WHEREOF, I have executed this Waiver.

TODAY’S DATE __________________ SIGNATURE____________________________________________

(Student (Parent or Guardian if student is under 18 years of age)

SIGNATURE REQURIED FOR ADMISSION INTO THE DAVIS CENTER

--------------------------------------------------------------Office Use Only-----------------------------------------------------------

(Course Information)

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Emergency Authorization Form

TO ALL EMERGENCY MEDICAL AND DENTAL CARE GIVING FACILITIES:

This is to certify that the Davis Center or anyone acting in behalf has my permission to act as

my agent on behalf of my child__________________________________________________ Born____________________________, in securing immediate medical or dental services in the event of accident or illness when I cannot contacted.

I accept full responsibility for any necessary expense incurred for the emergency medical or dental treatment of my child, which is not covered by the following:

Health Insurance Company________________________________________________

Policy Number#_________________________________________________

Type of Coverage________________________________________________

Medicaid Number#______________________________________________

Child’s Known Allergies or Physical Condition_______________________

Signature of Parent/Guardian______________________________________________ Print Name of Parent/Guardian____________________________________________ Date____________________________________________________________________ Home Address___________________________________________________________ City________________________________ State _________ Zip Code_____________ Home Phone_________________________ Work Phone________________________ Cell Phone______________________________________________________________ Email Address___________________________________________________________

Notary Public Signature___________________________________________________ Date____________________________________________________________________

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