Enrollment Form

Parent/Guardian____________________

Address ___________________________

_________________________________

Email: _________________

Home Phone _________Work_________

Student #1

Name:_________________DOB_________

Classes Desired ______________________

Student #2

Name:_________________DOB________

Classes Desired:______________________

Student #3

Name:_________________DOB________

Classes Desired:______________________

Is there any medical or other information

Concerning your child(ren) that may require

Special attention?_____________________
_________________________________________________________________________________________________________

I understand that lessons must be paid for whether attended or not and the monthly tuition is due at the first class of every month. A late fee of $10.00 will be applied and account must be paid in full in order to participate in any performances.

I release Harmonic Motion and its agents of liability for any injury arising out of participation in class and performances or incurred while on the premises.  In the event of a medical emergency, I authorize the agents of Harmonic Motion to secure proper treatment for said student.  I understand Harmonic Motion does not carry medical insurance for its students.  Medical expenses will be covered by the student’s own family insurance policy.

Parent/Guardian Signature:_____________________

Date: ________________