Student Name *
Student Name
Birth Date *
Birth Date
Address *
Home Phone *
Home Phone
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Phone *
Parent/Guardian Phone
Parent Guardian Work Phone
Parent Guardian Work Phone
Payment Plans: Plan A: Monthly Payment of $___ due the 1st week of every month and $10 Late Fee applied after the 10th. Plan B: Payment in full for the whole year only to receive a discount of 5% Registration Fees: Per Student: $30 Note: Upon submission of this form, please submit payment for your registration fee via and choose your subscription plan on our payment page (links at the bottom of this page).
Release and Authorization
Indicated in the space below are any health problems or conditions of which the studio should be aware (such as heart, back, medical, allergy, muscular, pregnancy, diabetes, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc.). I understand that 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, administrators, and executors, hereby waive and release Jess Widener individually and MovementWorks Dance and Fitness at St. Peter’s and its staff from any and all claims or damages of any kind arising out of my child’s participation in the exercise and/or dance program of MovementWorks Dance and Fitness at St. Peter’s. I further certify that the aforementioned student is in proper physical condition to participate in the exercise/dance program and that he/she has been examined by a licensed physician and found to be in proper physical condition to participate in said program. I, the undersigned, do hereby authorize Jess Widener or her designated agents (being teachers or administrators employed by MovementWorks Dance and Fitness at St. Peter’s) to obtain medical treatment for my said child in emergency situations where I cannot be reached in time to authorize the treating physician to provide such emergency medical services. I understand that I am responsible for any medical expenses and that the absence of health insurance does not make MovementWorks Dance and Fitness at St. Peter’s responsible for payment of medical expenses. This authority includes the power to authorize any and all treatment deemed necessary under the circumstances by a licensed physician. This power is in essence a power of attorney and shall remain in effect for one year from the date signed below.
Emergency Contact Information
(Food, Medicine, Etc.)
(i.e., blood transfusions, etc.)

I understand that one make-up class is permitted for each class my child misses. Make-up classes must be taken within 30 days of the missed class(es). I also understand that all fees paid are nonrefundable and nontransferable. The parent or guardian is responsible for notifying, in writing, Miss Jess of any change to your child’s enrollment status. The returned check fee is $35. Should this provision have to be enforced by legal means, the undersigned person(s) is responsible for payment, as liquidated damages, the costs of collection, plus interest at the legal rate and reasonable attorney’s fees as determined by the Court or 15% of the amount collected failing such determination.