Check here if this is a new email address| Name_______________________________________________ | |
| Address_____________________________________ | Apt#________ |
| City/Town________________________ | Postal Code___________ |
| Email____________________________ | Phone #_________________ |
|
Check here if this is a new email address |
|
Please check off the class/classes you wish to register for:
'80s Jazz ($25) Pop Jazz ($25) Clogging 4 Fun ($35)
'50s Tap ($35) Let's Go to the Movies ($45) Turn on the Tap ($45)
Fees: $______ Plus HST (13%) $_____ Total $________
WAIVER: I, the undersigned, personally and on behalf of my heirs, executors, administrators and assigns, hereby release and forever discharge the following:
1. The Burlington Footnotes Senior Performance Troupe Inc.
2. JMC Productions
3. All sponsors, organizers and volunteers of said organizations, their respective officers, directors, agents, representatives or successors, from any and all claims or demands that I have or my heirs, executors, administrators, assigns or any third party may have for personal injuries and property damage of any nature whatsoever, arising by reason of my participation or volunteering at any level of the organization's programs and productions.
I have read the above Statement, understood it and my signature confirms its acceptance. I attest and verify that I have full knowledge of the risks involved in my participation and I am physically fit and able to participate in said classes.
Signature: _____________________________ Date: ______
Witness Signature _______________________
Medical Information (i.e. allergies, medications, conditions, etc.):
______________________________________________________________________
Remember, classes may be cancelled if there is insufficient enrollment, so please register early to ensure availability.
Send completed registration form
and cheque to:
| JMC Productions 4180 Afton Court Burlington, ON L7L 1J6 |
For office use only Payment Received: Cash Cheque #_____Date: ______________________ |
Website: www.burlingtonfootnotes.org