POP STARZ™, INC. ("Pop
Starz™")
STUDENT SUBSCRIPTION & REGISTRATION FORM
THIS FORM MUST BE COMPLETELY FILLED OUT, PRINTED,
SIGNED, AND RETURNED
TO OUR OFFICE FOR ENROLLMENT TO BE COMPLETE.
IF PAYING BY CREDIT CARD, YOU MAY FAX
YOUR COMPLETED APPLICATION FORM AND PAYMENT INFO TO: 305-359-5118
* PLEASE NOTE THAT WHEN
USING YOUR CREDIT CARD TO PAY FOR TUITION, EVEN IF NOT
PAYING "ONLINE," THERE IS AN
ADDITIONAL $5.00 HANDLING FEE WHICH MUST BE ADDED ON
TO THE TOTAL REMITTANCE.
This form and
the Pop Starz™ Rules & Regulations, as modified from time to time, (excluding
Section 3: Release of Liability, Paragraph 2), and published on the Pop
Starz™ web site, (www.popstarzinc.com) are binding on all participants in
programs, classes and events sponsored by Pop Starz™. Consequently, you
should carefully read the following information and ask any questions that
are needed to permit you to understand the rights and obligations which
exist as a result of your association, or the association of the minor for
whom you are a guardian, with Pop Starz™. Please complete this student subscription
and registration form. Please make sure you provide all necessary signatures.
Once you have reviewed the class schedules, class locations, times and days,
and have chosen your appropriate skill level, you may choose to pay by credit
card or check. All credit card payments are required to have a signed registration
form on file, due to credit card company signature requirements, so please
be sure and print out this completed form and mail it to our corporate office.
There will be no payments accepted at the class. No students will be allowed
in class without all paperwork received by Pop Starz™, Inc. Please note
that after first class is attended, all payments are final, and no refunds
will be issued.
1.
REGISTRATION: Please fill out our registration
form. All applicable fields are required.
ABOUT STUDENT OR ABOUT PARENT IF STUDENT IS A MINOR
Name:
Street
Address:
City:
State:
Zip:
Day
Phone:
Night
Phone:
Cell
Phone:
Email:
ABOUT
YOUR CHILDREN IF APPLICABLE
First
Child's Name:
Date
of Birth:
School:
Second
Child's Name:
Date
of Birth:
School:
Third
Child's Name:
Date
of Birth:
School:
PLEASE
CHOOSE YOUR SESSION
ABOUT
YOUR CLASS
Please
select your level:
*
Family discounts for classes that meet for 2 hours a week:
$30.00 1st sibling $50.00 2nd sibling
* Family discounts for classes that meet for 1˝
hours a week: $15.00 1st sibling $25.00 2nd sibling
* Each student however is still responsible for one-time, $40
registration fee.
Club
Name and Location:
Days:
Times:
SECOND
CHILD IF APPLICABLE
Please
select your level:
*
Family discounts for classes that meet for 2 hours a week:
$30.00 1st sibling $50.00 2nd sibling
* Family discounts for classes that meet for 1˝
hours a week: $15.00 1st sibling $25.00 2nd sibling
* Each student however is still responsible for one-time, $40
registration fee.
Club
Name and Location:
Days:
Times:
THIRD
CHILD IF APPLICABLE
Please
select your level:
*
Family discounts for classes that meet for 2 hours a week:
$30.00 1st sibling $50.00 2nd sibling
* Family discounts for classes that meet for 1˝
hours a week: $15.00 1st sibling $25.00 2nd sibling
* Each student however is still responsible for one-time, $40
registration fee.
Club
Name and Location:
Days:
Times:
PAYMENT OPTIONS
If paying by check, mail your completed registration form
with your check to the address below.
If paying by credit card please provide your information
and mail in your completed registration form to the address below.
There is an additional $5.00 fee when paying by credit
card,
which MUST be added to your total amount!
Name:
Billing
Address:
(if
different from above)
City:
State:
Zip:
Day
Phone:
Night
Phone:
Credit
Card:
Account
Number:
Expiration
Date:
Issuing
Bank:
I continue to authorize Pop Starz to take out of my credit card the
amount of: >>>>>>><<<<<<< 10 days prior to the next new session and thereafter for
every consecutive session until I by certified mail, prior to the next
session beginning, ask that this agreement be discontinued. I fully
understand that there are no credits back to my credit card once the new
session that I paid for has begun.
Don't forget when signing up mid-Session, tuition
will be adjusted to the lower, pro-rated pricing.
Call for more details: 305-531-7224
Call
305-531-7224 with any questions or for assistance in filling out our
forms.
2.
Program Information:
Pop Starz™ holds six separate, eight week sessions per year,
with 55 minute classes held twice each week, or one hour and fifty minute
classes held once each week. Tuition is for complete sessions, without deduction
for absences, late enrollment or withdrawal. Specific program information,
including instructor backgrounds, special class requirements, class times
and other important information, is maintained on the Pop Starz™ website
(www.popstarzinc.com) and students must regularly check the website for
special announcements, including, if required, changes in class times and
locations. In addition to the tuition, each applicant must pay a $40, non-refundable,
one-time registration fee which must be included with this form. Only forms
accompanied by the required registration fee will be considered.
3. Release of Liability:
(General) As an adult and/or parent and/or legal guardian of the student(s)
listed above, the guardian is aware that hip hop dance is a strenuous physical
activity that involves a high level of activity and energy, which may place
student(s) at risk of pulled muscles, sprained ankles or other accidental
injuries. The adult and/or guardian understands and acknowledges that student(s)
is/are voluntarily participating in these activities with knowledge of the
danger involved and the guardian/student(s) assume any and all risks of
injury. In consideration of student(s) being permitted by Pop Starz™ to
participate in Pop Starz™ classes and/or performances, the adult and/or
guardian agrees that it, on behalf of student(s) and its/their legal representatives
or assigns, will not make a claim against or sue Pop Starz™, Bally Total
Fitness Corporation, or any of their affiliated organizations
for any injuries occurring to student(s) as a result of student(s) participation
in Pop Starz™ classes an/or performances, whether caused by the negligence
of Pop Starz™ or otherwise. In addition, the adult and/or guardian, on behalf
of student(s) and its/their legal representatives or assigns, release and
discharges Pop Starz™, Bally Total Fitness Corporation,
and their related organizations from all actions, claims, or demands that
the adult and/or guardian, on behalf of student(s) and its/their legal representatives
or assigns, now or in the future may have for any injury resulting from
student(s) participation in Pop Starz™ classes and/or performances. The
adult and/or guardian, as the legal representative of student(s), a minor
child/minor children, has carefully read the release language contained
above, understands that it contains a release of liability and signs it
of its own free will, and also have read, understand and agree to abide
by the policies and procedures as stated on the "Rules and Regulations"
page on the Pop Starz™ Website, located at http://www.popstarzinc.com/rules.html.
(Commercial) Pop Starz™ students and personel may, from time
to time, be subject to the permanent capture of visual imagery through available
instrumentalities (e.g., photographs, video tapes, live television, etc.)
and all such imagery shall be deemed the property of Pop Starz™, which is
authorized to use it for advertising or commercial purposes, as it deems
appropriate. In furtherance of the foregoing, the undersigned, on behalf
of the student, hereby irrevocably grants to Pop Starz™, perpetually, exclusively,
and for all media throughout the world (including print, non-theatrical,
home video, CD-ROM, internet and any other electronic medium presently in
existence or invented in the future), the right to use and incorporate (alone
or together with other materials), in whole or in part, photographs or video
footage taken of student as a result of the student's participation in workshop,
courses or approved activities of Pop Starz™ and acknowledges that since
the student's participation is of his or her own free will, the student
will receive no financial compensation, will not bring or consent to others
bringing claim or action against Pop Starz™ on the ground that anything
contained in the property, or in the advertising and publicity used in connection
therewith, is defamatory, reflects adversely on the student, violates any
other right whatsoever, including, without limitation, rights of privacy
and publicity. The undersigned, on behalf of itself and/or of the student,
hereby releases Pop Starz™, its instructors, agents, directors, officers,
successors and assigns, from and against any and all claims, demands, actions,
causes of actions, suits, costs, expenses, liabilities, and damages whatsoever
that the student may hereafter have against them in connection with the
foregoing. All photographs or video footage will only be used in conjunction
with advertisement or promotional purposes of Pop Starz™
and not be sold to a third party. If any monetary compensation
is received by Pop Starz™
in connection with the above, all talent will be compensated.
I
agree and accept the above terms on this day
of ,.
Student's Signature:
_________________________________________
Signature of Parent or Guardian:
_________________________________________
PLEASE
COMPLETE THE ABOVE STUDENT
SUBSCRIPTION & REGISTRATION FORM
1) PRINT IT
2) SIGN IT
3) SEND IT TO:
Pop Starz™ Inc.
5030
Champion Blvd #227
Boca Raton, FL 33496
IF PAYING BY CREDIT CARD,
YOU MAY FAX YOUR COMPLETED APPLICATION FORM TO: 305-359-5118
PLEASE MAKE ALL CHECKS PAYABLE TO: POP STARZ™
INC.
Call 305-531-7224 with any questions or for assistance in filling
out our forms.