Summer 2024 Registration Form

Contact Information
Name*
First Last
Phone*
Relation*
Email*
Medical Information
Emergency Contact (other than parents)*
First Last
Relation*
Phone*
Allergies/Medications
Disabilities
Consent Agreements
Liability & Injury Waiver*
I agree not to hold Daryl Jervis Dance Studio liable
While attending the Daryl Jervis Dance Studio, there is always possibility of injury. Daryl Jervis Dance Studio will provide responsible care for your child, but if some injury should occur, I agree not to hold Daryl Jervis Dance Studio, the owners, staff, or any of it’s chaperones responsible. I further authorize the agents of Daryl Jervis Dance Studio to obtain any and all necessary emergency health care, in my stead, for my child.
Date of Liability Waiver Consent*
MM slash DD slash YYYY
Photo Release*
I give consent to use any photo/image/video of my child
I hereby give consent for the Daryl Jervis Dance Studio to use any photo/image/video of my child (named above) in print, video, and/or electronic publications. I understand no financial compensation will be received. This agreement covers any photo/image/video taken during the dance season.
Date of Photo Release Consent*
MM slash DD slash YYYY

Dancer's Information