Form - Laya Bhava Dance Academy

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* Indicates required field

Student Name *

First

Last

Age *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Number *

Mobile Number *

Email *

Emergency Contact *

First

Last

Were you registered in LBDA in the past? *

Yes No

Phone Number *

Program (For more information on classes, please refer to the class descriptions under programs on our website. *

Recreational: Children (Aged 5 and up) Recreational: Adult Professional Training: Grade 1-7 (preparation for exams and arangetrams)

Please read below *

By checking this box, I am aware that there is a non-refundable registration fee of 25$. I am aware that once the term has begun, the class fees are non-refundable.

Please select your nearest location *

Waiver: I hereby release LBDA from liability for personal injury, loss or damage howsoever caused. In an emergency, I give permission to the physician to secure proper treatment, provided efforts have been made to reach my Emergency Contact. *

I agree

Photo Release: I hereby consent to and authorize the use and reproduction by LBDA, or anyone authorized by LBDA, of any and all images or photographs taken of me, and grant LBDA all rights to use these images/photographs in any medium. *

I agree I disagree

Laya Bhava Dance Academy (LBDA) is committed to protection and privacy. We never rent, sell, share or trade our mailing lists. Any personal information you provide is used for the purpose for which it was collected and keep you informed of news, events and fundraising opportunities in support of LBDA.

How did you hear about us? *

returning student flyer internet search witnessed a performance friend/family member

Choose Any *

By checking this box, you are registering as a LBDA student and give consent to all of the above.

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