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Participant Name * First Last
Primary Doctor Name * First Last
Primary Doctor Phone Number * ### - ### - ####
Emergency Contact * First Last
Emergency Contact Phone Number * ### - ### - ####
Check All Boxes Below: *
The Academy reserves the unrestricted right to dismiss any participant, without refund, whose conduct is inimical to the best interests of the Academy I will pay the tuition as per the published schedule. All photography and videography taken at the Academy may be used for promotional purposes.

As parent(s)/ guardian(s), we understand that by checking these boxes and submitting this form, we agree to these terms.
Parent/Guardian Name (Submitting this form constitutes your signature) * First Last
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