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2022-2023 Dance Registration Form

"*" indicates required fields

Child's Information

Child's Name*
MM slash DD slash YYYY
Choose Dance Classes*

Parent's Information

ATTENTION: Your monthly invoices will be sent to this email address

Emergency/Medical Release

I/we permit the dance instructor(s) of Teresa Clement Dance Studio to secure needed emergency care in case of an emergency when I/we cannot be contacted. I/we understand that any information I/we have provided will remain confidential within the Dance Studio program. I/we understand that Teresa Clement’s Dance Studio instructors are mandated under the social services law of New York State to report any suspected case of child abuse and/or neglect.*

Permission Emergency/Medical Treatment

In case of an emergency requiring medical treatment, I/we give permission for my child to receive such treatment services as are deemed in the best interest of the child at the time of the emergency. I/we accept financial responsibility for those services. If possible, I/we will be contacted prior to initiating treatment.
Hospital Address*

Medical Insurance Info

Policy Holder's Name*
Father/Guardian’s Name:*
Mother/Guardian’s Name*
I state I have legal custody of the child and request emergency services as indicated. The above info is correct to the best of my knowledge.*

Registration Fee

Registration Fee