Student First Name

First Name

Last Name

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Contact Person

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Grade

Academic School

Family Physician

Family Physician Phone

(###)

###

####

Family Dentist

Family Dentist Phone

(###)

###

####

Preferred Hospital

In case of emergency, can Infusion Dance transport your student to a nearby hospital, doctor, or dentist?

Yes

Enter Health Conditions, Allergies, Medications, etc. in the box below:

Electronic Signature

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.