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Provided with support from the Arts Council of S.W. Indiana; the Indiana Arts Commission, a state agency; and the National Endowment for the Arts, a federal agency

Special Thanks to:

Evansville Dance Theatre
Registration Form

Student Name:
Address:
City, State, Zip:
Home Phone:
E-mail:
Date of Birth:

Age:
Guardian:
Employer:
Work Phone:

2nd Guardian:
Employer:
Work Phone:
Physician:
Physician Phone:
Insurance Company:
Policy#:
Class Placement: (if attended previously)
# of Classes/wk: (plan to attend)

Waiver of Liability: I, the undersigned release and discharge Evansville Dance Theatre, Inc. and its staff, officers, directors, agents, and volunteers from any and all liability arising from, related to, or connected with any injury or illness or damage caused by or sustained in the course of any participation in classes, performances, or other activities conducted by or associated with Evansville Dance Theatre, Inc. I hereby attest that this Waiver of Liability is provided voluntarily upon submission of this form and shall be fully binding upon me, my heirs, next of kin, executor, administrator, and/or personal representative.

Additional Comments:
(NOTE: DO NOT send credit information with this form)



A Representative from Evansville Dance Theatre will contact you upon receiving this form to discuss method of payment.

Evansville Dance Theatre - 333 Plaza East Blvd, Suite E - Evansville, IN 47715
Phone: 812-473-8937       Fax: 812-473-0393
Last updated on August 2007