Please Fill out this form completely and then click "Submit Button"  at bottom of this page.

Credit Card type Mastercard Visa    Acct Number>>     Month on Card 01 Jan 02 Feb 03 March 04 April 05 May 06 June 07 July 08 Aug 09 Sept 10 Oct 11 Nov 12 Dec Exp Year 2011 2012 2013 2014  

<< Check this box for AutoPay with my credit card - MONTHLY
<< Check this box for AutoPay with my credit card - SESSION

 

By submitting this registration I have read and agree to the DABH studio policies below:
 By submitting this registration I Release and Agree to Waiver of Injury and agree to full payment with Credit Card on File agreement. I, do hereby voluntarily submit myself for attendance and participation in the Dance Academy of Bloomfield Hills and do hereby assume full responsibility for any and all damages, injuries or losses that she/he may sustain or incur in anyway while attending or participating in any Dance Academy of Bloomfield Hills classes or activities. I do hereby waive all claims against the instructors, the owners and/or operators, individually or otherwise, of the Dance Academy of Bloomfield Hills, for any injuries I may sustain while attending or participating in said programs. I fully understand that any medical treatment given to me will be for first aid only. This form can be photocopied for emergency treatment. For and in consideration of the acceptance of our child/children minor(s) in the programs offered by Dance Academy of Bloomfield Hills ("DABH"), we as parents and guardians of such minor(s), so hereby release and forever discharge DABH, its principals, employees and agents and their heirs, personal representatives, successors and assigns, and save them from harmless from and against any and all claims, actions, liabilities, damages and expenses in connection with loss of life, personal injury and/or damage to or loss of property arising from or out of the participation of such minor(s) in the programs of DABH. By reading and signing and or submitting electronically this legally enforceable Release, I/we acknowledge that I/we have carefully read and fully understand the provisions hereof. PHOTO RELEASE I grant permission to DABH, to use photographs and or video taken of me or my child for use on DABH web sites or other electronic form or media, and to offer the photographs for use or distribution without notifying me. I hereby waive any right to inspect or approve the photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photographs and or video. I hereby agree to release and hold harmless DABH, via electronic or media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any re-use, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in production of the finished product. I have read this release before submitting this online form, and I fully understand the contents, meaning and impact of this release. Credit Card on File. I agree to pay any and all balances I/we owe the DABH on a monthly or by the session with my Credit Card on file or the Credit Card information contained in this submission to the DABH. I understand a late fee of $25 will automatically be added to my balance and interest rate of 1.5% per month for each month balance is outstanding until payment in full is submitted to the DABH. By submitting this registration electronically, I agree and I authorize the DABH to process my balance on or prior to the June 2012 recital.