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

Summer 2010
IMPORTANT: PLEASE FILL OUT THE ENTIRE FORM

Circle all that apply-
Week 1 starting   7/12
Week 2 starting   7/19
Week 3 starting   7/26

Child Name:
Birthdate:
Address:
Zip Code:
Parent Name:
Telephone:
E-mail:
Emergency contact: IMPORTANT-we must have current/working phone numbers:
1.Your own Emergency Contact :
2.Another local Parent for Emergencies:
3. Responsible Person Outside the Area: :

How did you hear about our program?

Name of Doctor/Phone:

Please answer the following questions, explaining all “yes” answers fully on another sheet, so we can better serve your child:
Does your child have any special physical, behavioral, medical, or other needs?:
If yes, please describe and contact program director

Does your child have any allergies:                                    

How did you hear about our program?

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. I agree that my child may appear in photographs/video promoting the program.

Signature/Date__________________________________________________________________________