The Starlight Company Agreement

The Starlight Company Agreement & Registration form ONE-DAY FEBRUARY HALF TERM 2017 Mon 13th February 10am – 4pm (Drop off option from 9am available) THREE-DAY EASTER HOLIDAYS 2017 Monday 10th – Weds 12th April 2016 10am – 4pm (Drop off option from 9am available) 3:30pm Performance to parents at the end of each day Please complete form and email to [email protected] & contact us for BACS details OR send form with payment cash or cheques (made payable to The Starlight Company) to Rebecca White, The Starlight Company c/o 6 LITLEY CLOSE, HAMPTON PARK, HEREFORD, HR1 1TN.

STUDENT DETAILS Name ______Age (as of 13th Feb 2017) ______PLEASE CONFIRM DAYS ATTENDING & PLEASE INDICATE IF DROPPING OFF AT 9AM:

Book BOTH WORKSHOPS for £45 (10AM DROP OFF) Book BOTH WORKSHOPS for £50 (9AM DROP OFF) Book February 1 Day workshop £15 (10AM DROP OFF) Book February 1 Day workshop £17 (9AM DROP OFF) Book Easter 3 day Workshop £13 a day or £35 for all three (10AM DROP OFF) Book Easter 3 day Workshop £14 a day or £40 for all three (9AM DROP OFF)

February 1 Day workshop MON 13TH February 2017 ( ) 9AM Drop off ( ) Easter 3 day Workshop MON 10TH APR 2017 ( ) 9AM Drop off ( ) TUES 11TH APR 2017 ( ) 9AM Drop off ( ) WEDS 12TH April 2017 ( ) 9AM Drop off ( )

Date booked: TOTAL: £______

IF YOUR CHILD HAS ATTENDED A STARLIGHT WORKSHOP BEFORE AND NONE OF YOUR DETAILS HAVE CHANGED THEN PLEASE JUST SIGN OR PRINT AND DATE THE DECLARATION AT THE END OF THIS FORM.

EMERGENCY CONTACT 1 Parent(s) or Guardian(s) Name(s) ______Street Address ______City ______Post Code ______Daytime Phone ______Evening Phone______Mobile Phone ______Email Address ______HEALTH Does the student have or need assistance to participate due to a disability? NO ___ YES ___ If yes, please explain:______Describe any other medical condition you feel we should be aware of (diet restrictions, asthma, etc.)______DANCE HISTORY Is this the student’s first year of dance? ______Years of dance training completed ______Former/current dance school(s) ______How did you hear about us? ______PHOTOGRAPHIC RELEASE I agree that my child’s picture or likeness can be represented and published in any Starlight Company publication or local and national media. Signature ______Date ______(If left blank we will not take a photo) PAYMENTThere are no refunds given for any reason. I understand that if my child withdraws from the program during the workshop, that all fees and deposits are 100% non refundable. BACS, cash or cheques made payable to The Starlight Company. Person responsible for payment (leave blank if the same as “contact 1” above) ______Address: ______Phone ______By signing this form, the parent/guardian is assuming any and all responsibility for the student, including financial obligations. Signature ______Date ______

DECLARATION I (Parent/Guardian)name ______have enrolled (Student name) ______in a program of physical activity, offered by The Starlight Company. I hereby affirm that the above person is in good physical condition and does not suffer from any disability that would prevent or limit participation in this dance program. In consideration of myself, my heirs and assigns, hereby release The Starlight Dance Company, the owners Kim Owen, Rebecca White, Vicky Lightowler and Laura Lowe from any claims, demands, and causes of action arising from my or the above named person’s participation in any of the above stated programs, and I hereby release The Starlight Dance Company, the owners Kim Owen, Rebecca White, Laura Lowe and Vicky Lightowler, from any liability now or in the future including but not limited to heart attacks, muscle strains, pulls, tears, broken bones, shin splints, heat prostration, knee, lower back, or foot injuries and any other illness, soreness or injury however caused occurring before, during or after participation in any other of the above stated programs offered at The Starlight Dance Company or at any time, while in the vicinity of the premises of the above stated business, or in any activity sponsored, represented, or organized by The Starlight Dance Company, the owners Kim Owen, Rebecca White, Laura Lowe and Vicky Lightowler for any reason. By signing, I hereby affirm that I have read and fully understand and agree with the above waiver. Signature of Parent/ Guardian ______Date ______.

The Starlight Company www.starlightcompany.co.uk [email protected] 07912438309 Enrolment will not be completed until registration fee is received. Thank you for registering for The February and Easter Workshops 2017 with The Starlight Company