2023-24 Dance Season

Welcome Back!

We're super excited to kick off the 2023-24 dance season this September! As always, the season runs through the school year (September-May) with classes held Mondays-Thursdays after school. Your child's class schedule will be sent out at a later date.

*Ages 4 and up

Child's Information

First Name *

Last Name *

Date of birth *

Number of Classes *

Parent's Information

Parent's Name *

Email *

ATTENTION: Your monthly invoices will be sent to this email address

Phone *

Address *

City *

State *

Postal code *

Permission Emergency/Medical Treatment

In case of an emergency requiring medical treatment, I/we give permission for my child to receive such treatment services as are deemed in the best interest of the child at the time of the emergency. I/we accept financial responsibility for those services. If possible, I/we will be contacted prior to initiating treatment.

Known Allergies *

Doctor's Name *

Doctor's Phone *

Preferred Hospital *

Hospital's Phone *

Hospital's Address *

Hospital's City *

Hospital's State *

Hospital's Postal Code *

Medical Insurance Info

Insurance Company Name *

Insurance Policy Number *

Policy Holder's Name *

Policy ID Number *

Father/Guardian's Name *

Father/Guardian's Employer *

Father/Guardian's Employer Phone *

Mother/Guardian's Name *

Mother/Guardian's Employer *

Mother/Guardian's Employer Phone *

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.