TJC Academy of Dance Student Form Fall 2026 Session
Student information will be shared only with your child's Academy Instructors. Please type parent info carefully—this is how we stay in touch!
Child's Name
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First Name
Last Name
Parent Name:
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First Name
Last Name
Parent Name:
First Name
Last Name
Child's Date of Birth:
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Format: (000) 000-0000.
Primary Parent E-mail
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example@example.com
Parent E-mail
example@example.com
Dancer E-mail
example@example.com
Insurance Company (Medical)
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Policy Number:
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Policy Holder's Name:
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Child's Physician:
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Physician's Phone Number:
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Emergency Contact Name:
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Emergency Contact Phone Number:
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Does your child have any of the following:
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Asthma
Allergies (food, medication, environmental)
Diabetes
Seizure Disorder
Heart Condition
Physical limitations or injuries
ADHD or sensory sensitivity
None
Does your child carry an EpiPen or inhaler?
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Yes
No
Please list any allergies and reactions:
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Is your child currently taking any medication that we should be aware of? If yes, please explain:
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Please list any chronic illness:
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Does your dancer have any joint/muscle disorder or previous injury?
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Are there other variables that would impair movement or concentration this semester?
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If there are any other factors that would be helpful for your movement teachers to know, please list below:
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Medical Consent
In the event of a medical emergency, I ________ for staff to provide basic first aid and/or seek emergency medical care for my child if I cannot be reached.
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Do give consent
Do not give consent
Media Consent
I ______ my dancer’s NAME to be used in media publications.
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Do give consent for
Do not give consent for
I ______ my dancer’s IMAGE to be used in media publications.
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Do give consent for
Do not give consent for
TJC Academy of Dance Liability Waiver
Please sign your name below after reading
RELEASE OF LIABILITY AND INDEMNIFICATION AGREEMENT This is a binding contract. Please read carefully before signing. Parent/guardian must sign if the participant is under age 18. I represent and warrant that I am the Parent/Guardian of the child/participant listed below ("my child"). I hereby acknowledge that I have freely and voluntarily chosen to enroll my child in workshop(s) at Tyler Junior College ("TJC"). In consideration for my child's being permitted to participate in the Academy dance class at TJC and other valuable consideration, I hereby execute this Release of Liability with the intent to bind myself, my spouse (if applicable), my heirs, assigns and legal representatives. I further represent that I am eighteen (18) years of age or older and competent to sign this affirmation and release. I fully understand and agree that certain aspects of the Workshop could be physically demanding and that my child faces risks of accidental or other physical and/or emotional injury by participating in the Workshop. These risks may include, but are not limited to, (1) loss or damage to personal property, and (2) injury or fatality due to (a) use of electrical equipment, such as computers, and (b) walking, running, jumping, or other physical activity, or inclement weather and conditions, which may cause slips and falls. I understand these and other inherent risks and assume and accept all risks associated with my child's participation in the Workshop. I further represent that my child is in good physical condition, and does not possess, nor am I aware of, any physical or mental disabilities that will limit his/her ability to participate in the Workshop. I understand T JC is not responsible for any medical or other costs associated with an injury sustained by my child. BY SIGNING BELOW, I AGREE THAT THIS DANCE CLASS SHALL BE UNDERTAKEN BY MY CHILD AT HIS/HER OWN RISK AND THAT NEITHER TJC, ITS TRUSTEES, OFFICERS, EMPLOYEES, STUDENTS, AGENTS NOR ASSIGNS SHALL BE LIABLE FOR ANY INJURIES, DAMAGES, CLAIMS, DEMANDS, ACTIONS OR CAUSES OF ACTION WHATSOEVER THAT MAY ARISE OUT OF OR HAVE A CONNECTION WITH MY CHILD'S PARTICIPATION IN THE WORKSHOP, WHETHER FROM NEGLIGENCE ON HIS/HER PART, OR THE PART OF TJC OR ITS TRUSTEES, OFFICERS, EMPLOYEES, STUDENTS, AGENTS OR ASSIGNS, AND I DO HEREBY AGREE TO FOREVER RELEASE, DISCHARGE, INDEMNIFY, HOLD HARMLESS AND DEFEND TJC, ITS TRUSTEES, OFFICERS, EMPLOYEES, STUDENTS, AGENTS AND ASSIGNS FOR ANY INJURIES DAMAGES, CLAIMS, DEMANDS, ACTIONS OR CAUSES OF ACTION, INCLUDING ATTORNEYS' FEES, ARISING OUT OF OR RELATED TO MY CHILD'S PARTICIPATION IN WORKSHOP. The laws of the State of Texas govern and construe the terms of this Release of Liability.
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Submit
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