Register Online H1 section title 2022-2023 Dance Registration Form "*" indicates required fields Child's InformationChild's Name* Child's Date of Birth* MM slash DD slash YYYY Choose Dance Classes* Gymnastics Jazz Tap Ballet Hawaiian/Tahitian (ages 6 and up) Hip-Hop (ages 8 and up) Contemporary (ages 10 and up) Parent's InformationName* Email* ATTENTION: Your monthly invoices will be sent to this email addressAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Emergency Phone*Emergency/Medical ReleaseI/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.* Yes Permission Emergency/Medical TreatmentIn 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.Known Allergies* Doctors Name* Doctors Phone #*Preferred Hospital* Hospital Phone #*Hospital Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical Insurance InfoInsurance Co. Name:* Insurance Policy #* Policy Holder's Name* Policy ID #* Father/Guardian’s Name:* Father/Guardian’s Employer* Father/Guardian’s Employer Phone #*Mother/Guardian’s Name* Mother/Guardian’s Employer* Mother/Guardian’s Employer Phone #*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.* Yes Registration FeeRegistration Fee Pay Online Pay In Person Registration Fee* Price: Credit CardCard Details Cardholder Name Δ