Parent's Name *

First Name

Last Name

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dancer's Name *

First Name

Last Name

Dancer's Date of Birth *

MM

DD

YYYY

Do you agree with Viva's Payment Policy? *

I agree

I disagree

VIVA Ballroom | Dance | Fitness requires two months of payment upon registration. We use an automated system to collect the remaining monthly class fees. This is done through a checking account or credit card of your choice at the beginning of each month. If you wish to stop lessons, you must inform us in writing one month in advance and we will stop charges. First payment also includes a $30 registration fee. *

I agree

I disagree

Photo and Video Consent: Consent is granted for the student to be photographed or videotaped. These may be used without compensation in a public presentation. The student is free to refuse to be photographed or videotaped but must present a written form. *

I agree

I disagree

Injury Release: It is understood that the risk of physical injury is inherent in dance training. VIVA Ballroom Dance Fitness strives to reduce that risk through proper training techniques. However, by signing this form, the undersigned is willing to assume those risks and release, hold harmless, and indemnify VIVA Ballroom Dance Fitness, its related entities, instructors, employees, officers and representatives from and against any and all claims, demands, actions, judgments which the undersigned, or any person ever had, or may have against VIVA Ballroom Dance Fitness, for any losses, costs and expenses (including attorney’s fees) and damages or injuries known or unknown, real or personal, sustained by me or my child while in attendance and/or participating in all VIVA Ballroom Dance Fitness programs. *

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I disagree

Personal Property: It is understood that VIVA Ballroom Dance Fitness will not be held responsible for the loss or damage of personal property while in attendance and/or participating in any VIVA Ballroom Dance Fitness program. Physical Contact: Dance is an art form that requires teachers to be able to have appropriate physical contact for the purpose of making technical corrections. Consent is granted for such physical contact. Rules and Policies: The signature below implies that I have read and agreed to abide by the rules and policies of VIVA Ballroom Dance Fitness. This includes, but is not limited to, behavior that exhibits respect to fellow students and the teacher as well as the facility. *

I agree

I disagree