14701 NE Main #C2
Duvall, WA 98019 425-844-9086
Date:_________________
Name: Birthdate:
Address:___________________________________________________________________________
City, State, Zip:______________________________________________________________ Age:
Home Phone:
Cell Phone:
Allergies/Concerns:________________________________________________
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Emergency Phone:
Email:
Parents Names:
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Tuition is due at your 1st class of the month. Please Initial: _______________
Total monthly tuition $_______________
A late fee of $10 will be charged to tuition owed 1 month past due.
June Recital Participation: Yes No (circle one) Please initial:_________ Recital is June 21st, 2009 Please initial:_______
If you participate in recital, you will be required to make a $50 costume deposit by Dec. 1, and you will be required to participate
in either the opening number or finale number, in addition to your class dances.
If a costume is ordered, it is nonrefundable. Please initial:_______
TJ Dance reserves the right to use photos taken during the dance year for use on the website and newspaper. Please initial:_______
TJ Dance does not carry medical insurance for its students.
If injury occurs it is understood that the dancers personal medical insurance will cover all costs.
Medical Emergency Information
I give my permission for,Jayne Hancock and Peg Burnside and all of the staff and teachers at TJ Dance,
to get medical attention for my child,
in the event that a medical emergency should arise and I can not be reached.
Signature or Parent/Guardian Signature
__________________________________________________________
Health Care Provider/Dr. Name:
Phone Number
Emergency Contact: ______________________________________________________________________________________
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
Studios 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. We do 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.
Signature or Parent/Guardian or Adult Student
Date: _________
Please return this signed form with a $15 registration fee to reserve your place to:
TJ DANCE , 14701 NE Main St. Suite #C-2 Duvall, WA.. 98019 E-Mail: TJTAP@msn.com 7/2/08
