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

Winter 2010

Child Name:

Circle all that apply-class level and day:
Creative Movement (ages 4 and 5)   Mon or Wed
Ballet 1   Mon  or  Ballet 2  Wed     Perf Group?  

Age:
Address:
Zip Code:

E-mail:

How did you hear about our program?

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. Additionally, I agree that photographic/video images of my child can be used for promoting these educational classes.

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