Medical Form

Students Name *
Students Name
Birthday *
Birthday
Doctor's Phone
Doctor's Phone
Emergency Contact #1
Other than parents information (We will always attempt to contact the parents first.)
Contact #1
Contact #1
Day Phone
Day Phone
Cell Phone
Cell Phone
Emergency Contact #2
Other than parents information (We will always attempt to contact the parents first.)
Contact #2
Contact #2
Day Phone
Day Phone
Cell Phone
Cell Phone
Student Info
i.e., asthma, bursitis, etc.
Does student wear:
Liability Release
I/we hereby release Dance Divine, LLC, its agents, employees, and volunteer assistants from any liability whatsoever arising out of any injury, damage, or loss which may be sustained by the above-named student while participating in classes and activities offered by Dance Divine, LLC. In case of emergency, I/we grant any staff or faculty member of Dance Divine, LLC permission to seek medical care for the above-named student.
Parent Signature *
Parent Signature