POLICIES & FEES
330 McArthur Road Fayetteville, NC 28311
Class Registration Form
Emergency Contact Information
Emergency Contact Name
Please list any medical conditions that your child has including, but not limited to: asthma, diabetes, seizures, etc:
Please list type of medication your child takes for their medical condition:
Please list any allergies that your child has including, but not limited to: allergic to bee stings, peanuts, etc:
I understand that dance as with any sport, involves risk of injury to the participant. It is with that in mind, that I relieve Leslie Dumas, Leslie's Dance Academy, Inc., and Countryside Gymnastics of all liability in case of injury to my child. We will follow safety rules in dance.
Signature of Parent/Guardian:
Note: Please fill out the form before printing, signing and giving to Ms. Leslie!