Please fill in form completely
Full Name (*)
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Age (*)
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Birth Date (*)
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School and Grade Entering (*)
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Contact Information
Address (*)
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City (*)
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State (*)
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Zip (*)
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Home Phone (*)
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Work Phone (*)
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Alternate Phone (*)
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Email (*)
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Emergency Contact Name and Number (*)
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Registration Fee
A Registration fee of $20.00 ($30.00 per family).
Mail check made payable to Shannon DeFusco within 3 working days to 101 Shannon Court, Bristol, R.I. 02809
Agreement
If under the age of 18, the below agreement must be signed by a parent/guardian.
I understand with participation in dance there is a risk of accidental injury (such as there is in any physical activity), and that I, the undersigned, agree that Shannon's Studio of Dance Education, or any person associated with Shannon's Studio of Dance Education, will not be held liable for any such injury which is not caused by negligence on the part of the owner, instructor, or any employees of Shannon's Studio of Dance Education.
Signature and Date
Your full name typed in the above box constitutes an electronic signature.
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After filling out the registration form, please take a moment to fill out the questionnaire
in order for you or your child to be placed in the proper class/level.