Shalom Movement Online Registration

Registration

Already a customer? Click here to login.

Welcome to Shalom Movement School of Dance! Please complete the following registration form.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Home Phone

Work #

Cell # Receive Text Message Notifications

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

(Show-Hide Details)

Policies and Accountability

I've read the above and agree.

Release of Liability

I've read the above and agree.

Photography & Video Release

I've read the above and agree.

COVID-19 Wavier

Release and Waiver of Liability Concerning COVID-19
I, ________________________{guardian name} on behalf of
______________________________{students name}, myself, my personal representatives, heirs, executors, administrators, agents, and assigns, HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Shalom Movement School of Dance, its governing board, directors, officers, independent contractors, agents, volunteers and any students (hereinafter referred to as "Releasees") for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys' fees, litigation costs and expenses of any appeal), arising from any injury, health/medical diagnosis, property damage or death that I may suffer as a result of my participation in private solo lessons with instructor_____________________{instructor name}, REGARDLESS OF WHETHER THE INJURY, HEALTH RISK, MEDICAL DIAGNOSIS, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES, UNLESS THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES' GROSS NEGLIGENCE OR INTENTIONAL ACTS, AND REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH OCCURS WHILE IN, ON, UPON, OR IN TRANSIT TO OR FROM THE PROGRAM SITE. I further agree that the Releasees are not in any way responsible for any injury or damage that I sustain as a result of my own negligent or intentional acts.
Assumption of Risk.
I _________________________{guardian name} understand that there are potential dangers incidental to my and my child's participation in solo private lessons at Shalom Movement School of Dance, some of which may expose me to the risk of serious personal injuries, health risks, property damage, or even death. I understand that these potential risks include, but are not limited to: COVID-19 exposure, physical injury and other health risks. I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE ACTS OF THE RELEASEES, UNLESS THEY ARISE FROM THE RELEASEE'S INTENTIONAL OR GROSSLY NEGLIGENT ACTS, and assume full responsibility for my participation in the Program.
Indemnity.
I, ________________________{parents name} on behalf of myself, _________________________{students name} my personal representatives, heirs, executors, administrators, agents, and assigns, agree to hold harmless, and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys' fees, litigation expenses and costs of appeals), arising from any loss, injury, property damage, exposure to COVID-19 or death that I may cause or suffer as a result of my participation in dance lessons at Shalom Movement School of Dance, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES OR OTHERWISE, UNLESS THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES' GROSS NEGLIGENCE OR INTENTIONAL ACTS.
Signature of Parent/Guardian for Participants under eighteen (18) years of age:
I certify that I have custody of Participant or I am the legal guardian of Participant by court order. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I join with Participant in granting a release to Releasees as set forth in detail above.
__________________________________________________________________ Signature of Parent or Guardian Date
Page 1/2
I,_______________________{instructors name} agree to comply with cleaning standards before and after each lesson according to the EPA's List of Disinfectant Products for the specific products qualified by EPA under the Federal Insecticide, Fungicide, and Rodenticide Act for use against the COVID-19 virus. I understand that Shalom Movement School of Dance and owners John and Rebekah Hope Borthick are not responsible for my health or welfare during the independent contracting work I am providing. My engagement is by choice and at my own risk. I am receiving full compensation for these services provided.
Independent Contractor _________________________ ____\ ____\ ____ (date)
Signature of Parent/Guardian for Participants under eighteen (18) years of age:
I certify that I have custody of Participant or I am the legal guardian of Participant by court order. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I join with Participant in granting a release to Releasees as set forth in detail above.
_____________________________________________________________ Signature of Parent or Guardian Date

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

Registration

Referral Information

Family Information

Where do you live?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies and Agreements (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies and Agreements

(Show-Hide Details)