DNA kids
2013-2014 Registration Form
Please fill out one form for each individual dancer
Student Name: ______________________________________________________________________________
Circle One:
M
F
Birth Date: _______________________________________________________
Parent/Guardian Name: _______________________________________________________________________
Email: _____________________________________________________________________________________
Contact Numbers: Home: ___________________ Cell:__________________ Work:______________________
Mailing Address: ____________________________________________________________________________
City: _________________________________________ State:__________ Zip Code:_____________________
What interested you in this program? ☐Curriculum
How did you hear about DNA kids?
☐Location ☐Price ☐Schedule
Other: ______________
☐Flyer ☐Word of Mouth from _________________________
☐ Website/Advertisement in _______________________________ Other: _____________________________
PRICING TABLE
DNA kids Tuition (16 class semester): Please indicate class choice(s) on page 2**
Registration Fee (non-refundable):
Single Class:
*Early Bird Rate:
*Sibling:
Additional Class(es):
Afterschool pick-up:
Afterschool activities:
Choreography class:
Afterschool pick-up & activities:
Afterschool pick-up & choreography class:
Afterschool pick-up, activities, & choreography class:
TOTAL DUE:
$30.00
$500.00
$475.00
$450.00
$400.00
$50.00
$50.00
$80.00
$80.00
$100.00
$125.00
_______________
*Early Bird Discount of 5% cannot be combined with sibling discount; or applied to afterschool pick-up,
afterschool activities, or choreography class. Offer valid until August 16, 2013.
**Class Schedule: (Please select your class(es))
Monday
 2:30-3:15pm Yoga with Mind Body Dancer® (3-5)
 3:30-4:30pm Yoga with Mind Body Dancer® (6-10)
 4:30-5:15pm Creative Dance (3-4)
 5:15-6:15pm Contemporary (8-10)
Tuesday
 1:30-2:15pm Creative Dance (3-5)
 2:45-3:30pm Creative Dance (3-5)
 3:30-4:30pm Classical Ballet (6-9)
 4:30-5:30pm Modern Ballet (9-14)
 5:30-6:00pm Choreography Workshop (9-14)
 6:00-7:00pm Contemporary (10-13)
Wednesday
 10:30-11:15 Creative Dance (3-5)
 3:30-4:15pm Pre-Ballet (4-5)
 4:30-5:30pm Modern Ballet (7-9)
 5:30-6:00pm Choreography Workshop (7-9)
 6:00-7:00pm Classical Ballet (10-13)
Thursday
 11:00-11:45am Creative Dance (3-5)
 2:45-3:30pm Pre-Ballet (4-5)
 3:30-4:30pm Modern Ballet (5-7)
 4:30-6:00pm Modern Performance Workshop (10-14)
Friday
 10:00-10:45 Creative Dance (3-5)
 2:45-3:30 Hip Hop (4-5)
 3:30-4:30 Hip Hop (6-10)
 4:30-5:30pm Boys Dance (6-10)
Saturday
 9:30-10:15am Creative Dance (3-5)
 10:15-11:00am Pre-Ballet (4-5)
 11:00-12:00pm Yoga with Mind Body® (6-10)
 12:00-1:00pm Contemporary with Mind Body Dancer® (6-10)
Method of Payment (please circle): (Payment due on or before the first day of class)
Check (made out to Moving Visions) PayPal Cash (in person only)
You may email this form (3 pages total) to kids@dnadance.org or print and mail it, along with your payment, to:
Moving Visions Studio
19 Murray Street, 3rd Floor, New York, NY 10007
Release of Liability: I, as the legal parent or guardian of the above named student, authorize his/her enrollment
in the above classes and release DNA kids and its staff of all liability due to personal injury or loss of property. I
have read the DNA kids program material and agree to abide by the protocol and etiquette requirements. By the
very nature of the activity, dance carries a risk of physical injury, including but not limited to minor injuries such as
bruises and more serious injuries such as broken bones, dislocations and muscle pulls. No matter how careful the
teacher and the students are, the risk of injury cannot be eliminated. Sports or any activity that involve motion and
rotation carry with it a reasonable assumption of risk. DNA kids is bound by law to inform all participants and/or
their guardians of the risk involved in the activity of dance in general. In consideration for DNA kids accepting the
applicant and in consideration of the applicant having an opportunity to improve skills through the use of DNA
kids’ staff and facilities, those legally responsible for the named enrolling student realize the risk of injury involved
and hereby agree to assume responsibility of such for said student and further agree to save and hold harmless
DNA kids, its staff and teachers, and all other concerns, and indemnify them against loss intending to be legally
bound.
__ I’ve read the above and agree. (Please initial)
Photo release: In registering my child, I grant permission to use class or performance photos or videos for the
marketing of DNA kids. I agree to submit any objection in writing at the time of registration. I understand that
parents may only take photos and videos on observation days with the approval of each individual instructor.
__ I’ve read the above and agree. (Please initial)
Medical Release: I certify that my child has no condition that prohibits full participation in activities at DNA kids. I
assume all ordinary risks when my child is using the facilities and hereby release DNA kids, or any of its staff or
teachers, for any injury or damage suffered in connection with said use of the facility. In case of emergency, if I
cannot be reached, I authorize DNA kids, its agents and staff, to contact and secure necessary medical attention
for my child.
__ I’ve read the above and agree. (Please initial)
Enrollment Condition: I understand and agree that DNA kids has the right to terminate the enrollment of a child
if it is determined that the continued attendance of the child in the DNA kids program is not in the best interest of
the child or the program. I agree to supervise, or have a responsible adult supervise, my child before and
immediately after class.
__ I’ve read the above and agree. (Please initial)
Signature: _______________________________________________________ Date: _____________________