Student Name:     DOB:     Age: Mother's Name:    Father's Name: Guardian's Name (if applicable): BILLING INFORMATION (this address will also be used to send class notices unless you specify differently) Person Responsible For Payment:     Relationship: Address: City:     State:     Zip: CONTACT INFO. Home:     Cell:     Work: E-Mail: Are there any health concerns or allergies I should know about? How did you hear about Shining Stars Dance School? Class(es) you are registering for: Shining Stars Dance School strives to provide excellent instruction and care of your student. We do, however, provide training at the exclusive risk of the participants. Therefore, by submitting this form you agree not to hold Shining Stars Dance School or its employees liable for any injury while on the premises or due to dance instruction. You should have your own health or accident insurance. Also, by submitting this form you are stating that you have read and agree to Shining Stars Dance School's rules, policies, and payment schedule. REGISTRATION IS NOT COMPLETE UNTIL REGISTRATION FEE IS RECEIVED Date: Shining Stars Dance School 3616 B Towson Avenue (Almost at the corner of Fresno & Towson) Fort Smith, AR 72901 (479) 926-0784     v@shiningstarsdanceschool.com