Irene Rimer Dance Academy
International School of Dance & Club
ENROLLMENT FORM
Please fill out and send Via Email or Bring with you to Class!
EMAIL: irenerimer@msn.com scan or cut & paste
PLEASE FILL OUT ENTIRE APPLICATION, INITIAL THE SCHOOL POLICIES SECTION, SIGN AGREEMENT AND THE AUTOMATIC PAYMENT FORM
Personal Information Today’s date: _______________ Start date: ______________
Name ___________________________ Home Phone : __________________Cell/Beep:__________________
Address:___________________________________ Apt_________ City______________Zip _________
Occupation:____________ Age: ________ DOB: __________
E-mail address, Please PRINT: __________________________
Emergency Contact Information: If student is a child – Parent’s information
Name ______________________________ Relationship _________________Phone: ________________
Billing Information: Person responsible for payment _______________________Phone: _____________
Billing Address (if different from above) _____________________________________________________
General Information
How did you hear of us? __________________________________, Have you ever danced before? _______if yes,
what did you dance? _____________ How long did you train? _____________ Where did you train? ________________________
REGISTERING IN WHICH PROGRAM? ____________________________
SCHOOL POLICIES - Fees and Graduation
The school dance fees are paid on a monthly basis. No credits are given for absences. Our school rates are very reasonable and we are constantly providing our students with makeup classes. The studio will invoice the student every month and the student will owe the monthly fee unless a written cancellation is received. Your monthly fees are due on your “Start date,” There is a late fee of $15 after 5 days past due and a returned check fee of $35.
*Student will not level-graduate if all fees due are not paid before graduation
ABSENCES and/or VACATION
Students will not be able to graduate after one year if absent for more than two months out of the school year (unless for medical reasons.) Repeated absences cannot occur three months before graduation or student might not be able to graduate or participate in the any of the dance shows. Professional and/or advanced students will not graduate if absent for more than one month, unless for medical reasons.
CANCELLATION: 30 days withdrawal notice is required ! This agreement may be cancelled at any time; however, cancellations must be in writing to the attention of the Director or you may sign a withdrawal form 30 days prior to stopping classes. There is no penalty, however, at the time of cancellation, all past due fees must be paid. Students that come back after withdrawing will be subject to a new registration fee at current school rates. If the students does not wish to withdraw but to take vacation or for other personal reasons, he/she must notify the director, in this case the student’s membership will be on hold and will not have to re-register when returning.
I have read and understood all the above school policies: ______________ YOU MUST READ INSURANCE INFORMATION POSTED ON THE BOARD OF THE STUDIO AND ACCESSIBLE TO ENROLLING STUDENTS AND PARENTS! _________Initial!
Payment methods:
AUTOMATIC CREDIT CARD PAYMENT AUTHORIZATION: *Registration fee is not refundable
I ____________________AUTHORIZE DANCE ESSENTIALS LLC TO WITHDRAW FROM MY CREDIT CARD THE AMOUNT OF
________ FOR ______________________ EVERY ____ OF ________.
TYPE OF CREDIT CARD: _____________ CREDIT CARD NUMBER _________________________________________
EXPIRATION DATE _________________ SECURITY CODE ________________
CREDIT CARD HOLDER’S NAME: _______________________________ SIGNATURE: _________________________________
ACH AUTHORIZATION:
*Registration fee is not refundable
I ____________________AUTHORIZE DANCE ESSENTIALS LLC TO WITHDRAW FROM MY BANK ACCOUNT THE AMOUNT OF
________ FOR ______________________ EVERY ____ OF ________.
BANK NAME: __________________________ ABA: ___________________________________ ACCOUNT NO.________________________________
Please attach a VOID check with this form.
ACCOUNT HOLDER’S NAME: _______________________________ SIGNATURE: _________________________________
YOU MUST READ THIS INSURANCE INFORMATION!
OPEN AGREEMENT
WHEREAS, IRENE RIMER DANCE ACADEMY and DANCE ESSENTIALS, hereinafter “School”, is an institution established for the teaching, practice and demonstration of various dances; and WHEREAS, the above student seeks to enroll into a certain program for dance taught by the school, its teachers, agents and employees.
NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:
1- The undersigned student, his guardian or parents, fully understand the nature of the school, its ideology and in consideration of accepting the enrollment of the student, the student, his guardian or parents, agree to assume the risk of injury sustained by the student while engaging or attending training sessions, courses or lessons.
2- The student, his guardian or parents, expressly represent that they have sufficient insurance coverage for the purposes of payment for any medical, dental or hospital costs which may arise out of any physical accident or damages sustained by the student. Further, that said coverage shall be in full force and effect as to any liability to any party, person or entity which may be liable for any damages sustained. This insurance coverage shall insure to the benefit of the school wherein the school shall be deemed an additional insured.
3- The parties agree that the school, its teachers, agents or employees shall not be responsible nor liable in any manner to the student, his guardians, parents, heirs, personal representatives, beneficiaries, lineal descendants or dependents for any damages, injuries, medical expenses or whatever sort or form, for any injuries sustained by or caused by the student or any other person, as a result of an accident arising from any negligence during any lesson, demonstration, course or exercise on the school premises or any other activity emanating there from.
4- The student, his guardian or parents, for himself or herself, his/her heirs, personal representatives, beneficiaries, lineal descendants or dependents agree to make no claim against the school, its teachers, agents or employees and agree to indemnify and hold harmless the school, its teachers, agents or employees, against all claims, attorney’s fees, damages, loss or expenses which they may incur as a result of any claim or action which may be made or instituted against, by or on behalf of the student or his aforementioned representatives including but without limitation, to any cause or action based upon negligence of the school, its teachers, agents or employees.
_________ Initial