Wespac Dance

Westminster Performing Arts Center
5915 Westminster Blvd.
  WM , CA 92683
714.89.DANCE or 714.893.2623

REGISTRATION / INFORMATION FORM

STUDENT NAME: _________________________________   DATE: __________/________/________  

ADDRESS: ___________________________________________________________________________  

E-MAIL ADDRESS:______________________________   CELL PHONE:_______________________  

BIRTH DATE: _______________________HOME PHONE: __________________________________  

S.S. # (STUDENTS OVER 18)____________________________________________________________

IF STUDENT IS UNDER 18 PLEASE FILL OUT THE FOLLOWING:

MOTHER’S NAME: ___________________________________ S.S.#____________________________

MOTHER’S WORK PHONE:_____________________________

FATHER’S NAME: ____________________________________ S.S. #___________________________

FATHER’S WORK PHONE: _____________________________________________________________

NAME OF PERSON TO CONTACT IN CASE OF EMERGENCY:

___________________________________________PHONE: __________________________________

IS STUDENT CURRENTLY ON ANY MEDICATION? ______

IF YES, PLEASE LIST  _________________________________________________________________

ARE YOU ALLERGIC TO ANYTHING?   _________________________________________________

HEALTH INSURANCE: _________________________  POLICY #_____________________________

FAMILY DOCTOR: ____________________________ PHONE: _______________________________

HOW DID YOU FIND OUT ABOUT WESTMINSTER PERFORMING ARTS CENTER? ____________________________________________________________________________________

STUDENTS UNDER 18 PARENT MUST SIGN:

IN THE EVENT OF AN EMERGENCY, AND I CAN NOT BE REACHED, I HEREBY AUTHORIZE JASEIDA MOJICA, OR ANY OTHER AUTHORIZED ADULT IN ASSOCIATION WITH WESTMINSTER PERFORMING ARTS CENTER, TO ACT ON MY BEHALF TO PROVIDE EMERGENCY MEDICAL TREATMENT FOR MY CHILD FROM A LICENSED MEDICAL PROFESSIONAL. 

LIABILITY DISCLAIMER - WESTMINSTER PERFORMING ARTS CENTER AND THE INSTRUCTORS ARE NOT LIABLE FOR PERSONAL INJURIES OR LOSS OF, OR DAMAGE TO PERSONAL PROPERTY.  EACH STUDENT MAY DECLINE TO PARTICIPATE IN ANY ACTIVITY.  PLEASE INFORM INSTRUCTOR OF ANY PERSONAL LIMITATIONS YOU MAY HAVE.  IF YOU HAVE ANY DOUBT TO YOUR PHYSICAL ABILITIES, PLEASE CONSULT WITH YOUR PHYSICIAN BEFORE PARTICIPATING.   I HAVE READ AND UNDERSTAND THE RULES, DRESS CODE AND TUITION POLICIES OF WESTMINSTER PERFORMING ARTS CENTER. 

I HAVE RECEIVED A COPY OF THE RULES, DRESS CODE AND POLICIES.

PARENT SIGNATURE: ________________________________________________________________ DATE______________