Barrington Dance Academy Registration Form
Email address *
Student's First & Last Name *
Your answer
Student's Birth Date *
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/
DD
/
YYYY
Parent's First & Last Name(s) *
Your answer
Mailing Address *
Your answer
1st Phone Number *
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2nd Phone Number
Your answer
Name of Student's School
Your answer
Monday Classes
Tuesday Classes
Wednesday Classes
Thursday Classes
Friday Classes
Saturday Classes
As a voluntary participant, I recognize and acknowledge that there are certain risks of injury associated with any form of physical activity, including this activity. I affirm that my child has no physical, mental, or medical condition that to my knowledge would endanger my child or others if my child participates. I agree to assume the full risk of injuries, damages, or loss that my child may sustain as a result of participation. I hereby acknowledge that I understand the risks of participation and discharge Barrington Dance Academy, the Barrington Dance Ensemble, and its respective directors, insurers, employees, and representatives from any claims. My student’s photo or video image may be used in BDA marketing materials, including print and internet. I have read BDA’s Studio Regulations. Please check the box below to agree to these terms. *
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Please enter your name and the date *
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New Students - How did you hear about us?
If referred by a friend, please share the name:
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If other, please share how:
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