JKS Studio is taking registrations for the 2010-2011 dance year.
Semester 1 will run Aug – Dec & Semester 2 will run Jan – May.
We are excited to begin another year and look forward to what we can offer your child and our community.
Copy, Paste, and mail registration form along with $25.oo registration fee to PO Box 476, Caledonia, MS 39740
Student’s Name: __________________Sex: __ Age: __ Birth Date: ___/___/___
Mother/Guardian’s Name: ___________________ Father/Guardian’s________________________
Work Phone: __________ Cell: __________ Cell: ______
Address: ____________________ _________________ _______ ________
Street City State Zip
Home Phone: ____________________ Home E-mail___________________
Emergency Contact: _____________________ Phone: ________________
Are there any medical conditions to which we should be alerted? ____________________________________________________________________________________
Please list any medications your child is taking on a regular basis: ____________________________________________________________________________________
Acknowledgement of Risk and Waiver of Liability
Name of child(ren) participant(s) (if under 18): __________________________________________________________
I (we), _________________________________________________________, hereby give consent to the above mentioned child(ren) to participate in the JKS Studios. I recognize that potentially severe injuries, including permanent paralysis or death can occur in any activity involving height or motion, including gymnastics and related activities including tumbling, trampoline, and cheerleading.
I understand that it is JKS Studios intention to provide for the safety and protection of my child, and in consideration for allowing my child to use these facilities, I hereby release JSK Studios, its officers, employees, teachers, and coaches from all liability from any and all damages and/or injuries suffered by my child while under the instruction, supervision, or control of JKS Studios.
As legal guardian of the above mentioned child(ren), I hereby agree to individually provide for the possible future medical expenses which may be incurred by my child as a result of any injury sustained while training at or performing for JKS Studios.
This acknowledgment of risk and waiver of liability, having been read thoroughly and understood completely, is signed voluntarily as to its content and intent.
________________________________________ ___________________
Parent or Legal Guardian’s Signature Date
I hereby grant JKS Studios and its owners the right to use any photo and or other digital reproductions of my child or other reproduction of his/her physical likeness for publication processes, whether electronic, print, digital, or electronic publishing via the internet.
______________________________ ________________________
Parent or Legal Guardian’s Signature Date
Permission to Treat (optional)
I hereby give my permission to trained medical professionals to administer emergency medical treatment to my child, should sickness or accident occur in my absence.
______________________________ _______________________
Parent or Legal Guardian’s Signature Date
Insurance Information: (Please, mark if you Do Not have insurance O )
Provider:________________________ Group or ID Number__________________
Name of insured: __________________ Contact Number _____________________
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Where did you hear about us?_________________________________________________________________________
Preferable communication: (circle) Email Text Home Phone Cell Phone
Class Day Preference (Please circle 1st Choice): M T W Th F
Time Preference _________
Program(s) interested in: __________________________________________
