Student First Name *
Student First Name
Address *
Phone Number *
Phone Number
Cell Phone *
Cell Phone
Work Phone *
Work Phone
Family Physician Phone *
Family Physician Phone
Family Dentist Phone *
Family Dentist Phone
In case of emergency, can Infusion Dance transport your student to a nearby hospital, doctor, or dentist? *
I understand an injury could occur during dance class. I assume medical responsibility for my child and release Infusion Dance from any claim, liability, or demand for personal injury or property damage compensation.