EmailMe Form - Cyrious Movement Dance Studio

Dancer #1 Name *

First Last

Birthday (must be turning 4 by December 1st) *

MM / DD / YYYY

Allergies or Medication

Dance instructors will not be responsible for giving medications during class. Parent must be present

Dancer #1 Dance Experience *

No Dance Experience

Some Dance Experience with another Studio

Current CMDS Dancer

Dancer #1
Which Class are you Registering for? *

Dancer #2 Name

First Last

Birthday (must be turning 4 by December 1st)

MM / DD / YYYY

Allergies or Medication

Dance instructors will not be responsible for giving medications during class. Parent must be present

Dancer #2 Dance Experience

No Dance Experience

Some Dance Experience with another Studio

Current CMDS Dancer

Dancer #2
Which Class are you Registering for?

Parent Contact/Information

Parent/Guardian Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone *

### - ### - ####

Cell Phone *

### - ### - ####

Email *

Emergency Contact

Name of Emergency Contact *

First Last

Emergency Contact Phone *

### - ### - ####

Please Read and Check the boxes below

I Understand that Cyrious Movement and its employees/volunteers are not liable for personal injuries, damages or loss of personal property. Dance is a physical sport/activity and I know that sometimes, injuries do occur. All students are required to be covered by their own insurance held by their family. If injuries do occur, I understand that the student/families own insurance policy is the only source of compensation. *