Please give the names of two individuals other than yourself who will assume responsibility of your child in case of illness or accident until you can be reached. Please notify these individuals of these arrangments. Please notify The Dance Factory of any changes in writing. Emergency Contact #1 Name* Relationship to Child Phone* Emergency Contact #2 Name* Relationship to Child Phone* Child's medical conditions as they apply to dance Physicians name Office Phone Please notify your child's physician that they are dancing as it is a physical activity. Please discuss all physical & emotional needs your child have with The Dance Factory. The Dance Factory holds health and safety as an utmost importance. Instructors and staff are not responsible for injury resulted on location or at any The Dance Factory function. I authorize the faculty & staff of The Dance Factory to contact directly the persons named on this form and authorize above physicians to render treatment if necessary during an emergency in the event that the above said parents or persons named cannot be reached. The Dance Factory is hereby given permission to take action necessary in their judgement for the health and safety of the above said child. The Dance Factory is not babysitters or a day care service. Fees may be applied to students who have to wait for pick up once the studio closes. Any unauthorized use of The Dance Factory's name, images or students on the internet or personal websites are not permitted and will be subject to prosecution. I have read the information completely and understand no refunds will be made & all late payments are subject to $5 per week per class. Make up classes are available to classes missed due to illness or in-climiate weather. Student Parent/Guardian Date Fight Spam: What is 3 + 4 = ?