J.E.M.S. Dance Center Registration Form

(Please legibly print the entire form except the signature)

Student Name  _________________________________________________________________

Name of Parent/Guardian __________________________________________________________

 Address ______________________________________________________________________

(We need your complete address so we can keep you informed)

 Phone Number ______________________Emergency Phone Number ____________________

 How did you hear about JEMS? ______________________________________________

Which classes are you planning to enroll in? _____________________________________________ 

Please read and inital and sign below

I have received, read, and agree to abide by and be held accountable to all of the policies of J.E.M.S. Dance center. _______ I understand that there is some risk of injury associated with dance.  I agree to hold harmless and indemnify J.E.M.S. Dance Center and its owners, employees, and agents acting on its behalf in case of injury to the student.  I give my permission to any agent of J.E.M.S. Dance Center to obtain whatever medical attention they deem necessary for the student named above in the event of an injury.  I have full authority to authorize any and all medical attention without concurrence of any other individual.

Parent/Guardian Signature: ____________________________________Date ______________

Parent/Guardian Printed Name __________________________________

To print this information:  Hold down Control button and press P