Artistry In Motion Registration

How did you hear about us?*

   Newspaper Ad Other Performance Referral Telephone Book Website    Referral Name:          * - denotes required fields

Family Information:

Family Name:

Contact #1 First Name:*

 Last Name: * Type:* Father Gaurdian Mother Other

Home Phone: *

 Cell #:  Work #: 

Email:*

 (Emails are kept confidential)

Employer:

Employer Phone:

Employer Notes:

Contact #2 First Name:

 Last Name:  Type: Father Gaurdian Mother Other

Home Phone:

 Cell #:  Work #: 

Email:

 (Emails are kept confidential)

Employer:

Employer Phone:

Employer Notes:

Home Address: *

City: *

 State: * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NC ND NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY PR VI  Zip: *

Home Phone: *

Emergency Contact Info:
(Not Contact #1, Contact #2)

Health Insurance Carrier:

Student's First Name: *

 Last Name: *

Student Gender:

Female Male   Birth Date: *   (format=mm/dd/yy)  

Student Email:

School:

 Grade Level:                                                        preschool kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade college college-freshman college-sophomore college-junior college-senior Unknown value

Disabilites:

Allergies:

Medications:

Primary Doctor:

Click "Search" to be directed to class schedule, and select the class you wish to enroll in.

Classes

Select Class #1: *

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Select Class #2:

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Select Class #3:

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Select Class #4:

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Select Class #5:

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Release of Liability
As the legal parent or guardian, I release and hold harmless Artistry in Motion, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of Artistry in Motion, its owners and operators or in route to or from any of said premises.
I've read the above and agree.
 

Signature Text
As the legal parent or guardian, I release and hold harmless Artistry In Motion, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of Artisty in Motion, its owners and operators or in route to or from any of said premises.
I've read the above and agree.
 

Medical Emergency
The undersigned gives permission to Artisty in Motion, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restictions, or condition and/or declare the paricipant to be in good physical and mental health. I request that our doctor/physician ________________ be called and that my child be transported to ______________________ hospital. Please include physicians' phone number _______________.
I've read the above and agree.
 

Payment Information
Tuition is due by the first of each month. If accounts are paid after the tenth of the month, there will be a $15.00 late fee applied to the account balance. There is a $25.00 returned check charge for any checks returned by the bank.
I've read the above and agree.
 

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Comments:

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Credit Card Verification:

Name as it appears on card:

Card Type:

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Card Expiration Month:

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eCheck/Bank Draft:

Bank Name:

Bank Routing Number:

 (9-digit number)

Your Account Name:

 (Your name on your bank statement)

Your Account Type:

Checking Savings    Account Number: 

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