KATHRYN  ROSZAK
DANSE LUMIERE
6334 Kensington Avenue
Richmond, CA 94805
(510) 233-5550

Fall 2011

Child Name:

Circle all that apply-class level and day:
Creative Movement Monday
Ballet 1 and 2  on Monday
Ballet 2 and 3 on Wednesday
Ballet 3and 4 on Wednesday   

Age:
Address:
Zip Code:

E-mail:

How did you hear about our program?

Would you like information on Dance Summer Camps?

Parent Name:
Address:
Telephone:
Emergency contact:

Waiver:

I understand that Kathryn Roszak does not assume any liability for her classes.  I understand that dance is a physical activity and that my child is in good health for that activity.  I agree to inform the instructor of any special concerns or conditions regarding the health of my child.

Signature/Date_________________________________________________________________________