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Contact Information & Waiver Form
2008– 2009
Contact Parent/Guardian Name:
Street: Town: Zip:
Home Phone: Cell Phone:
2nd Parent / Guardian Name:
Please check here if you would like to be included in our KKO directory
How did you hear about us?
Emergency contact name: Phone Number:
*E-mail address:
*We keep all members updated by email; please supply the most currant email address you would like us to use.
Also, add KellyOsterNY@aol.com to your address book so you can receive our emails
Family Name:
| Dancer 1(full price) | Dancer 2 (full price) | Dancer 3 (half price) | Dancer 4 (no charge) | |
| First Name | ||||
| DOB | ||||
| Dance Level | ||||
| Location | ||||
| Uniform Size | ||||
| Deposit | $ | $ | $ | $ |
*Deposit due by 7/1/08. $150 per dancer (champions $200)
Child’s Allergies: Asthmatic? Yes No
Other Medical Conditions:
I acknowledge that this activity involves exertion and carries with it the potential for injury.
I hereby agree to waive the right to take legal action against the Kelly-Oster School, Carmel VFW,
Putnam Valley German-American Club, Bedford Presbyterian Church, Brewster Elks Lodge, Kerry Kelly-Oster,
Karyn Oster, and/or any affiliates and associates for injuries incurred on these premises. It is understood
and agreed that the participant is physically fit and prepared for participation in the activities which will be
undertaken, and that the participant has not been advised by any doctor or other medical person that
participation in these activities should be avoided and/or limited.
Parent/Guardian Signature: Date: