Dancer 1, Name: *

First Name

Last Name

Dancer 1, date of birth: *

MM

DD

YYYY

Dancer 2, Name:

First Name

Last Name

Dancer 2, date of birth:

MM

DD

YYYY

Parent / Guardian, Name: *

First Name

Last Name

Phone / Cell: *

(###)

###

####

Payment: *

I understand that $45 in the form of Cash, Check *made out to: Jamieson Irish Dance OR Venmo: @Katie-Jamieson-2 is due day 1 of of this program.

Yes

Waiver to participate: *

I agree not to hold Katie Jamieson / Jamieson Irish Dance liable for any injury, accident or loss while participating in any dance activity. If injury occurs, I understand that medical bills & other inconveniences of the injury will be handled by the family. I also confirm that my child / children are of healthy standing & are permitted to to participate in dance / exercise. I understand all terms of payments & agree to make payments by scheduled dates or pay the appropriate late fees.

Yes

Social media waiver: *

I approve the use of photographs of my child / children to be used in an advertising manner, ie: website, pamphlets, Social Media posts, etc.

Yes

No