REGISTRATION/RELEASE FORM
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                                               Heather's Studio
                                 Registration/Release Form




Student Name /Birthdate:______________________________

Parent Name:__________________________________________

Address:______________________________________________

Phone_______________________________________ 

Email:________________________________________________

                                        Medical Information

Medications:___________________________________________

Allergies:______________________________________________

Doctor's name /phone:____________________________________

Insurance carrier/policy number:____________________________

Emergency Contact/phone:________________________________

                                        Release of Liability

As the legal parent/ guardian of______________________I release Heather's Studio Inc. and hold harmless its owners and instructors from any and all liability, claims,demands,and cause of action whatsoever arising out of or related to any lost,damage or injury,including death that may be sustained by the participant and/or the undersigned of Heather's Studio,its owner,instructors or in route to or from any said premises.

                                     Medical Emergencies

The undersighned gives permission to Heather's Studio Inc. its owners and instructors to seek medical treatment for the participant in the event they are unable to reach a parent or guardian.I hereby declare any physical/mental problems,restrictions conditions and declare to be in good physical and mental health.I request our doctor/physican____________________ be called and that my child be transported to______________________Hospital.

                                    Payment Information

Tuition is due the frist of each month. Accounts paid after the 10th of the month,will be charged a $10.00 late fee.There are no refunds on monies paid (includes but is not limited to tuition,camps,clinics,uniforms,entry fees).We do not pro-rate tuition for missed lessons. I understand and agree to theses conditions.

Parent/Guardian Signature_____________________Date_______