Purple Charlotte Steppers Club

Registration Form
*Indicates mandatory fields.

*Name: ______________________________________________________________________________
Last First

*Spouse(if applicable)___________________________________________________________________
Last First

*Mailing Address: _____________________________________________________________________

Street/P.O. Box

_____________________________________________________________________________________
City State Zip

*Email Address: ______________________________________ Ph. Number_____________________

*Which class are you registering for? o Introductory o Beginner 1 o Beginner 2 o Intermediate

Are you interested in being a volunteer with PCSC? o Yes o No

Mandatory Exercise Release

I do hereby assume full responsibility for any and all damages, injuries, or losses that I may sustain or
incur, if any, while attending or participating in any dance class, demonstration, form of practice and/ or
physical activity. I hereby waive all claims against Purple Charlotte Steppers Club, its instructors, or
partners of said organization, individually or otherwise, for any and all claims for injuries or damages that I
might sustain.

I understand that there is risk of injury associated with participating in any form of physical fitness
including dance classes and activities with Purple Charlotte Steppers Club and I certify that I am in good
physical condition and have no known disabilities that might otherwise be detrimental to my health or
well-being. I certify that all of the information provided on this application is correct and true.

All applicants must sign. Parents or guardians must sign if applicant is UNDER 18.

Student Signature: ______________________________________ DATE: _____________________

Parent/ Guardian Signature: ________________________________ DATE: _____________________

*Students under age 18.