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Ballet With Miss Loren

3324 Chicago Road Suite 1N Steger IL


Registration Form
Please Print Clearly

Student Name: __________________________________ Age:____ Date of Birth:_________

Parent/Guardian:_________________________________________Relation: ____________

Address: ___________________________________________________________________

City: __________________________________________State: _______ Zip: ____________

Phone: _________________________________Cell: _______________________________

Email: _____________________________________________________________________

School: ________________________________________________Grade: ______________

How did you hear about us? ___________________________________________________

Class: _________________ Day/Time:_________________Tuition_____________________

Best way to contact you:_______________________________________________________

45 Min Class $88 ~ 1 Hour Class $96 ~ 1.5 Hour Class $112
Class Prices Are Listed In 8 Week Sessions
Make Checks Payable To LOREN HARN

WAIVER AND LIABILITY RELEASE


● In consideration of allowing participation in dancing / aerobics / physical activities in weekly classes
located within Room To Move Studio, the undersigned hereby agrees to waive any and all claims or
causes of action that the participant has, or may have in the future, due to any personal injury or
property damage that might result from participation in any exercise, dance, workout, or other activity,
whether under the supervision of any independent instructor or by the participant’s own direction.
● The undersigned agrees to release Loren Harn and Room To Move Studio from any and all liability for
any loss, damage, injury or expense that they participant may incur, or that the participant’s next of kin
may incur, as a result of the participant’s participation in any activities with Loren Harn and Room To
Move Studio, due to any cause whatsoever. By signing this release, the undersigned acknowledges and
understands that: (1) He/She is aware of the risks, dangers, and hazards of participating in any activity;
(2) He/She is over 18 years of age, and if he/she is not over 18 years of age, the signature of a parent or
legal guardian below indicates that the parent or legal guardian has read and understands the language
in this document and has signed it voluntarily.
● The undersigned further agrees to allow Loren Harn to take and use photographs of classes for
promotional use. (names will be withheld)

Student Name:______________________________________________________________

Signature of Responsible Party:_________________________________________________

Date:_____________________ Class:___________________________________________

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