enrollment – Justines Dance Academy

Full Name

Phone

Address

Emergency Contact Name

Emergency Contact Phone

Are you currently on medication?

Yes No

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Are you affected by any of the following?

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Have you recently...

Sought Therapy or Counseling Had Surgery or Attended physical therapy Been Pregnant None of the above

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Please describe in detail any other health or medical condition that you believe may be helpful for us to know:

I agree to the following:
1. The information I have provided on this form is complete and accurate.

2. I understand that participating in an exercise class involves risk of injury; I agree to be solely responsible for any injuries sustained by me as a result of my participation in this class or any future classes I take with Justine's Dance Academy. I am fully aware of the risks involved.

3. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the dance class. I represent and warrant that I am physically fit and have no medical conditions that would prevent me from participation in my classes. I assume full responsibility for any injuries or damages, known or unknown, which I might incur as a result of participating in the dance sessions. I knowingly, voluntarily, and expressly, waive any claim I may have against for injuries or damages that I may sustain as a result of participating in the classes. Please share digital signature (full name)plsl

SIGNED:

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Justine's Dance Academy Enrollment Form