Daddy Daughter Dance 2018
Please complete the form below to register your child/dad for the Daddy Daughter Dance 2018
Questions? Please contact Kristin @ KristinPSMD@gmail.com | 704.971.2011 or Anne@ AnnePSMD@gmail.com | 704.932.8888
$85.00 Per Couple
Student's Last Name *
Your answer
Student's First Name *
Your answer
Dad/Male Participant's Last Name *
Your answer
Dad/Male Participant's First Name *
Your answer
Participation Fee *
The card on file with PSMD will be debited/charged $85.00 within three business days, and I understand this fee is non refundable.
Required
Participation Fees are Non Refundable *
Once participation fees have been charged to the card on file, they are may not be refunded or credited.
Parent's Telephone Number *
Your answer
Emergency Contact Telephone Number *
This should be someone other than the Dad/Male participant's phone number. Please include name and number.
Your answer
Parent's Email Address *
Your answer
Medical Release *
On behalf of my child and her dad, I assume the risk associated with dance and agree that Piedmont School of Music & Dance (PSMD) and its faculty, volunteers and owners shall not be liable in any way for any injuries sustained or loss of property during attendance at the school or any of its related functions. I hereby grant permission to the Director and/or Staff of PSMD to authorize the hospital admission and medical and emergency treatment in case of emergency, accident and illness and only in case the parent/guardian can not be contacted.
Media Release *
I agree that Piedmont School of Music & Dance has the right to use the name, photograph, voice or other likeness of this student and may exhibit same through any medium whatsoever for advertising, promotional or commercial purposes. All such reproductions shall be the exclusive property of the Piedmont School of Music & Dance.
Parent Signature *
Your answer
Submit
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