Please select:
Majorette     Dance     Tumbling       Cheer

STUDENT INFORMATION

Student's Name:     Birth Date:   
Address:     City:     Zip Code:    

Child's Shirt Size      Child's Pants Size 

Mother's Name:     Cell Phone:    
    Work Phone:

 Father's Name:     Cell Phone:    
    Work Phone:
 

ALL OTHER PERSONS AUTHORIZED TO PICK UP CHILD:

1. Name:     Relationship to child:     Phone:
2. Name:     Relationship to child:     Phone:
3. Name:     Relationship to child:     Phone:

How did you hear about our studio?

Please list prior dance experience (i.e., number of years, technique studied, teachers, etc.):

PAYMENT INFORMATION

Tuition is due by the 1st Saturday of every month. A $10 late fee will be assessed to all payments received after and students will not be allowed to attend class until account is current.

I understand that all fees paid are nonrefundable and nontransferable. The returned check/declined card fee is $35. Should this provision have to be enforced by legal means, the undersigned person(s) is responsible for payment, as liquidated damages, the costs of collection, plus interest at the legal rate and reasonable attorney’s fees as determined by the Court or 15% of the amount collected failing such determination.

Indicated in the space below are any health problems or conditions of which the studio should be aware (such as heart, back, medical, allergy, muscular, pregnancy, diabetes, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc.). I understand that risk of injury is inherent in any physical activity and I, on behalf of myself and my child, knowingly and voluntarily accept that risk. I, the undersigned, for myself, my heirs, administrators, and executors, hereby waive and release Jennelle Spurlock individually and Imani Dance Academy, LLC. and its staff from any and all claims or damages of any kind arising out of my child’s participation in the exercise and/or dance program of Imani Dance Academy, LLC. I further certify that the aforementioned student is in proper physical condition to participate in the exercise/dance program and that he/she has been examined by a licensed physician and found to be in proper physical condition to participate in said program. I, the undersigned, do hereby authorize Jennelle Spurlock or her designated agents (being teachers or administrators employed by Imani Dance Academy, LLC.) to obtain medical treatment for my said child in emergency situations where I cannot be reached in time to authorize the treating physician to provide such emergency medical services. I understand that I am responsible for any medical expenses and that the absence of health insurance does not make Imani Dance Academy, LLC. responsible for payment of medical expenses. This authority includes the power to authorize any and all treatment deemed necessary under the circumstances by a licensed physician. This power is in essence a power of attorney and shall remain in effect for one year from the date signed below.

PayPal e-mail address of individual responsible for payment:

EMERGENCY INFORMATION

Physician:     Hospital Preference:
Insurance Company Policy No.:
Allergies (food, medicine, etc):
Additional Information/Comments (i.e. blood transfusions, etc) :
 

CLASSES BEGIN SEPTEMBER 8, 2018

MANDATORY PARENT MEETING AUGUST 25th @ 11AM

       

 

 
 
 

9830 Lake Forest Blvd Ste 122
New Orleans, LA 70127
504-261-2145