Student Registration Form – Dance , Stretch , Strength
Instructor : Seth Miller
Ice Box Sports Center , 21902 Telegraph Rd , Brownstown , MI 48183 Ph . 734 676-5500 www . iceboxsports . com
Student ’ s Name : __________________________________________ Date of Birth ______________________ Address : ______________________________________ City : _______________________________________ State : _____________________ Zip : ________________ Home Phone : ________________________________ Parent / Legal Guardian Name : _________________________________ Cell Phone _______________________ Email : _______________________________________ _____________________________________________ Please list any health concerns , medications , allergies , etc : __________________________________________
_________________________________________________________________________________________
I do authorize emergency first aid care , to the above named student , by Ice Box Sports Center , or its agents and representatives in the event he / she becomes injured or ill during instructional programs or other activities either on or off premises .
Classes are held on Monday , Wednesday and Thursday , 9:00am to 9:45am Please list all classes that you are registering for
Session 1 |
June 17 , 19 , 20 |
____ $ 30.00 |
Session 2 |
June 24 , 25 , 26 |
____ $ 30.00 |
Session 3 |
July 1 , 3 ( no class July 4 th ) |
____ $ 20.00 |
Session4 |
July 8 , 10 , 11 |
____ $ 30.00 |
Session 5 |
July 15 , 17 , 18 |
____ $ 30.00 |
Session 6 |
July 22 , 24 , 25 |
____ $ 30.00 |
Session 7 |
July 29 , 31 , Aug . 1 |
____ $ 30.00 |
Session 8 |
Aug . 5 , 7 , 8 |
____ $ 30.00 |
Session 9 |
Aug . 12 , 14 , 15 |
____ $ 30.00 |
$ 40.00 Discount
when Registered for
ALL 9 sessions
TOTAL :
_____________
I , ( state full name )_______________________________________________, parent / legal guardian of the above named student fully understand , recognize and am aware of the risk and hazards involved in the activities of dance provided by Ice Box Sports Center . I acknowledge , agree and represent that I understand the nature of such activities and that I am of the opinion that above named student is qualified , in good health , and in proper physical condition to participate in any and all activities provided by Ice Box Sports Center . I hereby discharge , covenant not to sue and release the Ice Box Sports Center , Great Technique Dance Academy , Seth Edward , its agents , directors , employees , volunteers and all other associates from any and all liability , claims , responsibility for any and all harm and injury which may be sustained by above named student during attending class or participation in activities and programs sponsored and directed by the Ice Box Sports Center . I hereby give my consent to the Ice Box Sports Center for photographs and / or video of above named student to be used for promotional purposes in newspapers , on TV and on the Website ( s ) at anytime for any reason . I waive any and all right to payment ( s ) for use of these photographs and / or video . I understand that this waiver does not expire .
Parent / Legal Guardian Signature : ____________________________________ Date : __________________