Student Name

Parent / Guardian

(for class notices, etc. – please use one you check frequently)

Mailing Address

Class(es) Enrolled

Complete for each class of enrollment

Total Hours Per Week:

(if applicable)
(if applicable)

Consent Agreement

Island Dance Academy will not assume responsibility for any injury resulting from misuse of equipment or failure to comply with the instructions of our staff. I hereby certify that my child is in good physical condition and is able to participate fully in this program. All current and up to date physical conditions are outlined above.

By checking this consent box I the parent or guardian of, release Island Dance Academy and its teachers from liability in case of accident or injury that may occur while attending classes at Island Dance Academy on or off site. I have also read and understand the School policies.

PLEASE BE ADVISED that classes may be documented by photo and video. These may be used for publicity purposes. If you do not want your child’s image to be used, please check here: