Emergency Contact Form

Dancer Information

Child's First Name

Child's Last Name

Home Phone

Cell Phone

Parent/Guardian Email

Street Address

City

Region/State/Province

Postal / Zip code

Emergency Contact Information

Primary Emergency Contact

First Name

Last Name

Relationship

Emergency Contact Cell Phone

Emergency Contact Home Phone

Emergency Contact Work Phone

Secondary Emergency Contact

First Name

Relationship

Last Name

Emergency Contact Cell Phone

Emergency Contact Home Phone

Emergency Contact Work Phone

Insurance Information

Company

Insurance Policy Number

In the event of an emergency InJustis Dance Inc., LLC has my permission to consent for treatment. I fully release and discharge InJustis Dance Inc., LLC & their affiliates of any liability in the case of injury or accident in connection with my child's participation.

I agree to the terms & conditions

Today's Date

Parent Signature

Thank you for submitting your emergency contact information!