Registration Form

Move & Groove Dance Program Student Registration

Student Name: _____________________________________________

Age: ____________________________________________________

Date of Birth: ______________________________________________

Responsible Party: __________________________________________

Address: _________________________________________________

City: ____________________________________________________

Zip: _____________________________________________________

Contact Phone: _____________________________________________

Email Address: _____________________________________________

Name of School / Location: _____________________________________

If your child is at  Country Home Learning Center please circle what you are registering for:

Dance only                   Tumbling only                  Dance AND Tumbling

Waiver/Release Form
I understand the risk of injury in any type of dance program. I will not hold Ronda Runnels or any of her instructors liable for injuries sustained during a dance class at any facility where the Move & Groove Dance Program is taught.

Parent Signature: _____________________________________________

Date: ______________________________________________________