Enrollment Form

Child’s School_______________________________________

Course Name________________________________________

Child’s Name________________________________________

Birthday / /___ circle one (M) (F) Start Date___/ /___

Parent or Guardian____________________________________

Address_____________________________________________

___________________________________________________

Home Phone#( )____________________________________

Other Phone #( )____________________________________

Email_______________________________________________

Please mail this form, registration fee, and first month’s tuition to

Jump Into Motion Dance Academy

PO BOX 2492

Anderson, IN 46108-2492

First Month Tuition $______

Registration Fee $5.00__

Total Amount Enclosed $______

**LIABILITY REALEASE**

I, the undersigned, hereby acknowledge that I have voluntarily

applied for the services of Jump Into Motion Dance Academy.

I understand that my child remains under the care of their school

and Jump Into Motion Dance Academy and their employees are

not liable for any injury or damage caused during class

or as a future result of instruction.

Child’s Name_______________________________________

Parent or Guardian Name______________________________

Signature________________________________Date_______