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Dancer's name:


D.O.B.


Age:


Medical info (allergies, etc):

Mother's name:


Cell phone:


Work phone:

Father's name:


Cell phone:


Work phone:

Billing address:


Home phone:


Emergency contacts and numbers:

Classes - Please circle

Ballet/Pointe

Jazz

Hip Hop

Modern

Tap

Contemporary/Lyrical

Preschool


Summer Session


Fall Session

I authorize KATJ to consent to medical treatment for my child/myself if I cannot be reached to give permission.  I am fully aware that the activities at KATJ create the possibility of injury and further agree to hold KATJ and its owner and staff  (whether paid or volunteer) harmless for any injury, illness or resulting expense during the course of classes, competition, workshops or traveling to and from an event.  I give permission to use photos or images of my child in brochures, websites, social media posts and newspapers.


Parent signature:


Date: