Student Registration

Student full name

Student Birthday

Month

Day

Year

Age

Student Gender

Female

Male

Other

Student Pronouns

Class Selection

Primary Address

Parent/Guardian 1 (Primary Contact)

Parent/Guardian 1 Phone

Parent/Guardian 1 Email

Parent/Guardian 2

Parent/Guardian 2 Phone

Parent/Guardian 2 Email

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship to Student

Please list any medical conditions or allergies below. Leave blank if none.

List any regular medications below or leave blank if none.

Consent and Waivers

I hereby give permission for the student named above to participate in dance classes at Leaping Willow Academy.

I understand that dance is a physical activity and, as such, carries the risk of injury. I agree not to hold Leaping Willow Academy liable for any injuries or accidents that may occur during classes or events.

I consent to emergency medical treatment if necessary.

By providing your phone number, you agree to receive text messages from Leaping Willow Academy.

I consent to the use of photographs and videos of the student for promotional purposes (e.g. website, social media, advertising, etc.). No personal information will be shared.

By attending Leaping Willow Academy, I voluntarily assume all risks related to Covid-19. I commit to do my part and comply with all restrictions set in place for my (my child’s) safety and the safety of others. I understand and assume all risks related to exposure to COVID-19. I also understand, that should I show any COVID-19 symptoms, I will not be permitted to come into the studio.

Additional comments or requests. Leave blank if none.

How did you hear about us?

Signature

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Shore Cultural Centre Room 245

291 E 222nd St. Euclid, OH 44123

Student Registration

Consent and Waivers