I state I have legal custody of the child and request emergency services as indicated. The above info is correct to the best of my knowledge.

I/we permit the dance instructor(s) of Teresa Clement Dance Studio to secure needed emergency care in case of an emergency when I/we cannot be contacted. I/we understand that any information I/we have provided will remain confidential within the dance studio program. I/we understand that Teresa Clement Dance Studio instructors are mandated under the social services law of New York State to report any suspected case of child abuse and/or neglect. I/we understand that Teresa Clement Dance Studio is not liable for any bodily injuries that my child may have picked up during classes.