BLACK PANTS GIRL SEPTEMBER 2019 REGISTRATION & WAIVER
Please complete this ONLY if you are a PASSHOLDER, interested in signing up for a PASS or you are wanting to sign up for the entire class SESSION. Everything other than the WEDNESDAY @ 8:15 PM class is a 4 week session.

SEPTEMBER SESSIONS BEGIN = TUESDAY 9/3/19, WEDNESDAY 9/4/19, THURSDAY 9/5/19 AND MONDAY 9/9/19.

When you do this, you will be sent an invoice to pay immediately (or at least provide a deposit) - passholders will pay as scheduled. YOU MUST BE PAID IN FULL BEFORE CLASS STARTS.

We'd love to have you dance with us...there's room on the dance floor for EVERY BODY!

Your Full Name *
Your answer
Your Email Address *
Your answer
Your Phone Number *
Your answer
WHAT SESSIONS DO YOU WANT TO TAKE? *
Required
Your Date of Birth (MM/DD/YY) *
Your answer
Would You Like to Be on our Email List? *
A Person to Call In Case of Emergency (Full Name and Phone Number Required) *
Your answer
WAIVER SECTION (LIABILITY / PHOTOGRAPHY)
I realize that participation in dance classes and activities could involve some possible personal injury. Despite precautions, accidents and injuries may occur. By signing this release form, I (the dancer), assume all risks related to the use of any and all spaces used by Anna Rogers (aka Black Pants Girl).

I agree to release and hold harmless Anna Rogers (aka Black Pants Girl), its booked teachers, dancers, staff members, and facilities used from any cause of action, claims, or demands now and in the future. I will not hold Anna Rogers (aka Black Pants Girl), liable for any personal injury or any personal property damage, which may occur on the premises before, during or after classes. Furthermore, I agree to obey the class and facility rules and take full responsibility for my/our behavior in addition to any damage I may cause to the facilities utilized by Anna Rogers (aka Black Pants Girl).

I give full rights to Black Pants Girl, Anna Maria Rogers/Terlinden and any guest instructors to use photos and video images of me and/or my child to use for promotional purposes of Black Pants Girl, Anna Maria Rogers/Terlinden and any guest instructors. Photos and video will be used in brochures, websites, advertisements, social media and other promotional material created by Black Pants Girl, Anna Maria Rogers/Terlinden and any guest instructors. Photos may appear with or without names in press releases, print advertising or online.

***I will always be given the opportunity to remove myself from photos or videos when taken as asked by instructor, photographer/video-taping individual/s.***

Type Your INITIALS as your Signature Agreeing to Waiver Above *
Your answer
THANK YOU FOR REGISTERING FOR CLASSES!
An invoice will be sent to you as soon as possible, remember payment is due either in part to or full to hold your spot as soon as possible. Thank you for joining in the movement with us - Anna Maria Terlinden Rogers (BLACK PANTS GIRL).
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