Registration Form

(Please Print)
Name ____________________________________ Age _____ Birthday ________ Grade _____
Street Address __________________________ City ____________ State ______ Zip ________
Billing Address (If different) _______________________________________________________
Mothers Name _______________________________ Cell # ____________________________
Fathers Name _______________________________  Cell # ____________________________
Home # ____________________________________  Work # ___________________________
E-mail _______________________________________________________________________
Academic school ______________________________________________________________
In case of an emergency, call ______________________________________________________
Favorite color _______________________ Food allergies _______________________________
Total years of dance __________________ Total Years of dance with Odyssey ________________
How did you hear of Odyssey Academy of Dance? ______________________________________

Classes registering for:

Class __________________________ Day/Time _____________________________________
Class __________________________ Day/Time _____________________________________
Class __________________________ Day/Time _____________________________________
Class __________________________ Day/Time _____________________________________
Class __________________________ Day/Time _____________________________________
Class __________________________ Day/Time ______________________________________________

Attention Parents: Unless Odyssey Academy of Dance receives written notification from you prior to any publication, your child’s enrollment, registration, attendance and/or participation in any event and/or activity associated with Odyssey Academy of Dance shall constitute your permission for and consent to allow your child’s name and/or image being published on Odyssey’s website and/or any other media, electronic or otherwise, associated with Odyssey and to your indemnification of Odyssey Academy of Dance, its agents, employees, and assigns, related to said publication. I agree to release and hold harmless Odyssey Academy of Dance for any injuries sustained by me or my minor child that may be caused by participation in dance class, rehearsals or other forms of activity.

                       Signature                                                                                       Date