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WEST HAWAII DANCE ACADEMY

REGISTRATION FORM
                                           
Student

Name__________________________ Age _______________ Birth date _________________________

Address ___________________________________ Home Ph. _________________________________

City/State ____________________ Zip _____________School ___________ Grade_____________

Father's Name ________________________ Mother's Name _________________________________

Address ______________________________ Address _______________________________________

City/State/Zip _______________________ City/State/Zip ________________________________

Phone(h) ___________ (w)______________ Phone(h) ________________ (w)__________________

Employer _____________________________ Employer ______________________________________


Adult Responsible for Payment ________________________________________________________

Address, If Different from Above _____________________________________________________

Any Heath Problems? _________________________________________________________________

In case of emergency, please notify __________________________________________________

Preferred Classes ____________________________________________________________________

I have read West Hawaii Dance Academy's tuition and school policies. 
I am responsible for the full tuition for the class(es) for which I am registering and 
understand that tuition is non-refundable and payable in advance.

I am aware, as with any physical activity, that dance can be a risk ?or personal injury. 
I expressly assume such risk and waive any and all claims or causes of action against 
West Hawaii Dance Academy, Theatre, Dance Centre, its Instructors and Contractors, 
owners of B & K Commercial Park, and Yumi Hancock arising out of or connected with my 
or my child s participation in classes and activities, including, but not limited to, 
claims from injuries.


Signature of Parent or Guardian ___________________ Date _______ Witness ______________

The signing of this form constitutes your contract for the full amount of fees. 
All fees are due prior to taking the first class. Missed classes must be made up within 
two weeks of absence.

Registration Fee $10 ______ Paid(Date) ____________ Tuition paid _______________________

74-5626	Alapa Street Bay 15 Kailua-Kona, HI 96740 Ph.
(808) 329-8876 FAX (808) 329-1033 e-mail vh2dns4@ ilhawaii.net

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