Student Information Form

Name of Person Making Payment:

Name of Student:

Email:

Main Phone (please specify home or cell - if cellphone, add name):

Emergency Phone and Name of Emergency Contact:

Address:

City, State, Zip:

Student Allergies or Concerns:

Student Healthcare Provider (Dr's name):

Student Healthcare Phone:

Student Birthdate:

June Recital Participation: Yes  No  Not Sure

Please describe which classes you are interested in taking:

Terms of Service - User Agreement:

Tuition is due at your 1st class of the month. If you pay past the 10th of the month, $5 will be added to your tuition due.
I Agree

Dance instruction may require instructors to touch the dancers body for proper placement.
I Agree

You will be required to make a $25 costume deposit in November and $25 in December (due by Dec 10) or a costume will not be ordered for you or your child. If a costume is ordered, it is nonrefundable. You or your child will be required to participate in either the opening number or finale number, in addition to your class dances.
I Agree

TJ Dance has my permission to use candid photos taken during classes and performances.
I Agree

Medical Emergency: TJ Dance does not carry medical insurance for its students. If injury occurs it is understood that the students personal medical insurance will cover all costs. I give my permission for the Dance Teachers, Jayne Hancock and Peg Burnside, to get medical attention for my child, in the event that a medical emergency should arise and I cannot be reached.
I Agree

Liability Release: I hereby release the TJ Dance instructors, any guest instructors, any adults in charge, and the owners of the land and building of TJ Dance’s residency from any liability resulting in accident or injury while participating in any activity at TJ Dance. This also includes any activities in the waiting area or parking lot. TJ Dance does not supervise the waiting area or the parking lot. I certify that my level (or my child’s level) of physical condition determined by my physician or myself allows me to safely participate in classes. My signature states that I have read and understand this liability release.
I Agree