Dillard Street Elementary Registration Please note that all fields followed by an asterisk must be filled in. Parent/Guardian First Name*
Parent/Guardian Last Name*
E-Mail Address*
Street Address*
City*
Zip/Postal Code*
Cell Phone*
Student's Name*
Grade*
Classroom Teacher's Name*
Music Class *
---Select--- Musical Theater - TBD
Dance Pop Fusion - TBD
Rhythm Rage - TBD
Where will your student go after their music class?*
---Select--- Walker/Biker
Parent Pick-Up
ASP
Do you authorize OPMI to use photos of your child on our website and/or promotional material?*
---Select--- YES
NO
OPMI Payment Policy* OPMI Liability Waiver*
BY CHECKING THIS BOX, I AGREE THAT I HAVE READ AND VOLUNTARILY SIGNED THIS AGREEMENT ELECTRONICALLY and further agree that no oral representation, statements, or inducement apart from the following written agreement has been made: IN CONSIDERATION, of being permitted to utilize the facilities, services and program of ORLANDO PREMIER MUSIC INSTRUCTION, herein after referred to as 'OPMI', for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with OPMI, the undersigned, for himself or herself and any personal representatives, heirs, children and next of kin, hereby acknowledges, agrees and represents that he or she releases OPMI and its staff members from all liability for an injury, loss or damage connected in any way whatsoever to participation in OPMI activities whether on or off of the premises affiliated with OPMI. He or she understands that this release includes any claims based on negligenc
Special Requests/Needs/Concerns:
