Manners, Character Development, Empowerment & Social Dance Seminar

Interest List

Child 1 First and Last Name: ________________________________________________________
Child’s Age: ______________________________________________________________________

Child 2 First and Last Name: _________________________________________________________

Child 3 First and Last Name: _________________________________________________________
Child’s Age: ______________________________________________________________________

Emergency Contact Name: __________________________________Relationship______________
Home Phone: _____________________________________________________________________
Cell Phone: _______________________________________________________________________
Parent’s Email Address: _____________________________________________________________

Emergency Contact Name and Number:________________________________________________

How did you hear about the program? __________________________________________________
Children’s Food Allergies? ___________________________________________________________

Have you referred other families to this year's session? Who? ______________________________


Referral Discount: A referral discount is offered when you recommend other families to register during the same session as your child.

Medical Liability Release: Dancing is recreational exercise. Therefore it is your responsibility to check with your doctor that this activity is safe for your child to do. You are participating in this activity at your own risk and are advised to carefully follow your instructor's directives to stay safe and keep those you are dancing with safe from bodily injury. The student assumes all risk, danger and injury incidental to dancing or related activities, whether occurring before, during or after the actual taking of the lesson. The student(s) agree(s) that the owner, members, partners, agents, landlords and teachers of the Back to Basics Program are not liable for injuries resulting from any causes related to dance instruction from us and releases and holds harmless such persons and entities, regardless of whether any injury or loss is caused by any person(s) negligence or otherwise. The jurisdiction for any disputes is in the General District Court of Alexandria, VA.

Cancellations: Classes may be rescheduled, cancelled or relocated at the discretion of the Director, due to insufficient enrollment, or other conditions she deems beyond her control. All registered students will receive phone notification and refunds for cancelled sessions.

Dress Code:
Girls- Dress or skirt at or below knee height
Boys- Suit and tie

Discipline: Students who are repeatedly disruptive in class, in the opinion of the Director, will be asked to leave the program. A pro rated refund will be given to the student and admission to future programs is solely at the discretion of the Director.

Photos and Video: Parents, guardians, and students grant TWDS use of any recorded images of themselves for promotional purposes. The identity of the child will always be kept confidential.

By signing the Registration form, the signer acknowledges and agrees to be governed by the rules outlined on this form.

____________________________________________ Date__________________
Signature of Parent or legal guardian

Email or fax this form to:
Back to Basics
Attn: Deborah Joy Block
FAX (888) 580 - 7753