ARTS IN MOTION DANCE STUDIO
REGISTRATION FORM
2007-2008

How did you hear about us? (Circle One) AT&T Yellow Pages/Other phone book/Referral/Door Hanger/
AA Observer/Current/Metro Parent/Ann Arbor Family/Website/Other:____________________________.
Student Information:_____New Student_____Returning Student
Student's First Name:__________________Last Name:________________
Gender:_____________________________Birth Date:________________
Address::__________________________________________________________
City:_______________________________State:___________________Zip:______________________
Student Email:________________________Phone:__________________________________________
School:_____________________________Grade:___________________________________________
_____Yes! Please contact me about the Ride Service
Disabilities:___________________________________________________________________________
Allergies:_____________________________________________________________________________
Medications:__________________________________________________________________________
Primary Doctor:________________________________________________________________________
Contact #1 First Name_________________Last Name_______________Relationship_______________
Home Phone:________________________Cell #___________________Work#___________________
Email:______________________________(emails are kept confidential)
Contact #2First Name_________________Last Name_______________Relationship_______________
Home Phone:________________________Cell #___________________Work#___________________
Email:______________________________(emails are kept confidential)
Emergency Contact Info:________________________________________________________________
(other than parents) ____________________________________________________________________
____________________________________________________________________________________
Health Insurance Carrier:________________________________________________________________

Classes:
Title: _______________________________Day: ___________________Time:_____________________
1.____________________________________________________________________________________
2.____________________________________________________________________________________
3.____________________________________________________________________________________
4.____________________________________________________________________________________
5. ___________________________________________________________________________________

_____I am enclosing my non-refundable annual $15 registration fee (one per family).
Please call 734/222-6246 to schedule your appointment to complete the registration process.

I recognize the necessity of occasional physical contact with instructors and the risks of illness and injury inherent
in any dance program. I am participating upon the express agreement and understanding that I am hereby waiving
and releasing Arts in Motion, its directors, employees, and agents of all claims, except for illness and injury directly
resulting from gross negligence or willful misconduct on the parts of AIM, its directors, employees or agents. I further
acknowledge that any photographs or video images of myself/my child are the property of AIM and may be used for
publicity purposes with the understanding that AIM will not publish names, addresses or phone numbers along with
the images.
Signature____________________________________Print Name__________________________Date___________

For multiple students, please copy this form and fill out one per student.