Beverly Rogers Academy of Dance SUMMER REGISTRATION
3322 North Friendship Road
PADUCAH, KENTUCKY
270-442-1100

2019 Summer Registration Form

A form must be filled out for each student.
Please contact the office with updated information if it changes.
No registration fee for new students for summer camps
Payment Type
Parent Guardian Information
Parent or Legal Guardian Name *
Your answer
Address *
Your answer
City *
Your answer
Zip *
Your answer
Email *
Your answer
Phone *
Your answer
I have read the following Waiver of Liability *
I the parent or legal guardian, for and in consideration of the benefits derived from his/her child participating in Beverly Rogers Academy of Dance do hereby give approval for participation in this activity. I assume all risks and hazards incidental to such participation including transportation to and from all activities; and do so hereby waive, release , absolve, indemnify and agree to hold harmless the Beverly Rogers Academy of Dance, organizers, sponsors, supervisors, participants and persons transporting students or participants to and from all activities, for any claim arising out of injury to the student. The undersigned also agrees to carry medical expenses and be responsible for any and all expenses which may arise from the participation of the above child in any Beverly Rogers Academy of Dance event.
Required
I agree with the Waiver of Liability *
Required
Dancer's Information
Dancer will be attending *
Dancer First Name *
Your answer
Dancer Last Name *
Your answer
Dancer's Birthdate *
Your answer
Age
Your answer
Gender *
School Attending Fall 2019 *
Your answer
Class Selection
Check if interested in:
Previous Dance Experience
Your answer
Primary Phone # *
Your answer
Mother's Name *
Your answer
Mother's Cell #
Your answer
Father's Name
Your answer
Father's Cell #
Your answer
How did you hear about us?
Your answer
Insurance
By checking the box below affirms that I now have and will continue to carry proper medical,health, and hospitalization and accident insurance which I consider adequate for the protection of my child at Beverly Rogers Academy of Dance.
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