CiM's STUDENT ENROLLMENT FORM
This form must be returned along with the your first session's tuition in order to hold your space in class.

Student's Name: ___________________________________________ Date of Birth: ____________
Student's Name: ___________________________________________ Date of Birth: ____________

Address: ________________________________________  Home Phone #: ___________________
City/Zip: __________________________________________________________ Grade: _________
Parent: _______________________________________ Cell or Work #: ______________________
Parent: _______________________________________ Cell or Work #: ______________________

Email Address: _________________________________________________________
* We will send all statements, notices, newsletters, etc. to this email.

Referred by: Friend's name: ____________________    Website    Yellow Pages    Other: __________

Enroll me in the following (list title/day/time & 1st or 2nd choice next to each):
____________________________                         ____________________________
____________________________                         ____________________________

(Check one)   I am paying for the:       ____ school yr     ____ session
(Check one)   I am enrolling for the:    ____ school year (optional recital)     ____ session #

Amount Enclosed: ___________      CK#: ___________

MAIL TO: CIM c/o L Boyer, 48 Chester Ave, Cville, PA 19320

 

** Please list any medical conditions, which might be affected or aggravated by participation in any activities, connected with Creativity in Motion's classes: _________________________________________________________________

NOTICE: Laura Boyer/Creativity in Motion urges all students to obtain a physical examination from their physician, prior to the use of any equipment or attendance in any exercise/dance class in recognition of the possible dangers connected with any physical activity. Students/parents/visitors knowingly and voluntarily waive any right or cause of action of any kind whatsoever arising as the result of any occurrence from which any liability may or could accrue to Laura Boyer/Creativity in Motion, its owners, officers, agents, landlords, employees or instructors. The students or their parents hereby assume all risk and responsibility if any injury should occur. The students and their parents understand the policies of Laura Boyer/Creativity in Motion and will abide by them; failure to do so may result in suspension or expulsion from classes or activities with the program.

_____________________________________________________              _____________________
Signature of Parent/Guardian/Adult Student                                                        Date