Registration

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Thank you for filling out and submitting our Registration Form. Once completed and sent to us, you will be able to log into our Parent Login. A $25 registration fee per family is required with our regular session classes.

*   denotes required fields

Family Information
Where do you live?
Additional Info
Contact #1
How Can We Contact You?
Portal Access (your email is your login)
(Emails are kept confidential)
Contact #2
How can we contact you?
(Emails are kept confidential)
Student #1
(format=mm/dd/yyyy)
Additional Info
Required Policies and Agreements
I, THE UNDERSIGNED PARENT AND/ OR GUARDIAN, understand that the risk of injury is inherent in any
physical activity, and I, on behalf of myself and my child, knowingly and voluntarily accept that risk. I, the
undersigned, for myself, my heirs, executors and administrators, hereby waive and release Cynthia Hixson,
individually, and Dianna Durkin Dance Studio and it's staff from any and all damages of any kind arising out of my child's
participation in the dance program/performances at/with Dianna Durkin Dance Studio. I further certify that the aforementioned student is in
proper physical condition to participate in the dance program. I do, hereby, authorize Cynthia Hixson or the staff of
Dianna Durkin Dance Studio to obtain medical treatment for my child in emergency situations where I cannot be reached. I
understand that I am responsible for the payment of any medical expenses and in no circumstances is Cynthia Hixson
or Dianna Durkin Dance Studio responsible for payment of medical expenses. This authority includes the authority to
authorize any and all emergency treatment deemed necessary by a licensed physician.


-I grant permission for any photo/images/video of the student above, to be published as advertisement, on Dianna Durkin Dance Studio's behalf, in a safe and tasteful manner, carefully selected by the staff of Dianna Durkin Dance Studio. I understand that no compensation will be allotted for the
use of these photographs or videos.

I authorize Dianna Durkin Dance Studio to charge my credit card on file the 1st of each month (September - May) for my child/children's tuition fee. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Dianna Durkin Dance Studio in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I acknowledge that the origination of the Credit Card transaction to my account must comply with the provisions of U.S. law. I certify that I am the authorized user of this Credit Card and will not dispute these scheduled transactions.


-I I have read completely, understood fully, and agree to all of the Dianna Durkin Dance Studio's financial and other policies.
-I understand this waiver does not expire.

I Agree to All of the Above
Questions or Concerns
Payment Information
Credit Card