Registration Form

Your Name (required)

Your Email (required)

Your Parents Name (required)

Your Address (required)

Your Home Phone Number (required)

Your Cell Phone Number (required)

Your Emergency Phone (required)

Your Emergency Contact (required)

Your Allergies/Health Problem (optional)

Your Medication (optional)

Your Medical/Liability Waiver (required)

I am/my child is in good health and have/has permission to participate in the dance class. In the event of an accident or any other medical emergency , I give the instructor Nilanjana Banerjee my permission to obtain and authorize medical treatment from health care providers for myself/my child and to release any medical information to the health care providers. I do hereby waive and release the instructor, Nilanjana Banerjee from any liability arising out of injury to me /my child.

I agree  Standard Waiver Policy

Parents Signature (Upload a Photocopy)

Date of Submission (required)

  • RDM studio page