Dance Studio Student's Registration Form

Last Name*

First Name*

Middle Name

Birth Date*

MonthDayYear

Student's Age*

Please select dance genre(s)

Level of Experience*

BeginnerIntermediateAdvancedProfessional

Parent Name*

First & Last

Parent Phone*

Parent Email*

Parent Address*

Street # Street Name Unit # City Zip Code

Parent Name

First & Last

Parent Phone

Parent Email

Parent Address

Street # Street Name. Unit # City Zip Code

Is student free from infectious desease or conditions?*

YesNo

Are immunications up to date?*

YesNoImmunization Exemption

Any activity the student should be restricted from?*

Any physical, mental or other condition that would require special attention or medication while in class?*

List any past medical treatment that would be helpful for us to know.*

Insurance Company*

Insurance Policy #

List all medications the student takes on a regular basis.*

List any allergies (ex: bees,peanuts, dairy), and the severity of the allergy.*

Any dietary needs that we should know about?*

By hitting submit and electronically signing, I agree that I am the parent or legal guardian of the above named student, and am over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. I give my permission for the Attitude Arts Academy to transport, or call an ambulance, to take my child to a medical/dental facility, if necessary. In case of emergency, if none of the emergency contacts respond, I hereby give my consent for emergency medical care to be prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent. I accept full responsibility for all costs of said medical care and any emergency treatments. The Attitude Arts Academy will not be held responsible for the cost of any medical or dental care, or emergency treatments. I hereby waive all claims whatsoever in connection with such medical treatments.

Electronic signature:*

Student's Information

Health Information

Health Release