PARTICIPATION INFORMATION
McLean Community Center Fall 2016
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CLASS *
Check all that apply. Specify which student in which class in the "other" field.
Required
STUDENT(S) FIRST AND LAST NAME *
PARENT FIRST AND NAME ("N/A" if over 18) *
PRIMARY PHONE NUMBER *
Please enter most accessible number first: Cell, Home, or Work
SECONDARY PHONE NUMBER *
Cell, Home or Work
STREET NAME *
CITY, STATE, ZIP *
EMAIL *
STUDENT(s) DOB *
STUDENT AGE *
EMERGENCY NAME *
EMERGENCY PRIMARY PHONE *
EMERGENCY SECONDARY PHONE
RELATIONSHIP *
ALLERGIES? *
Please list applicable or NKA (No Known Allergies)
Allergy Symptoms
MEDICAL CONDITIONS or DISABILITIES? *
Please list applicable or NK (None Known)
Medical Symptoms; Medications
List directions or times for medications.
Media Release (please enter initials): *
The JOD staff may take photographs or videos of students, individually or in groups, attending or taking part in classes, programs and events.These photographs or videos may appear in publications, on our website or in other publicity. Students and/or participants consent to having their photograph taken or such videos shown and used for such purposes. If you do not wish for you or your child to be photographed or video recorded, you must notify the JOD office in writing to that effect.
Please read and agree with the statement below: *
By checking this box (below) and submitting this form, I agree and I recognize the risks of accident inherent in any exercise, dance or gymnastics program.  I waive, release, and hold harmless Joy of Dance, LLC, Marilyn Baird, her heirs, assigns, instructors, employees and/or independent contractors, McLean Community Center, its Board Officers, employees and agents, the County of Fairfax, its Board Officers, employees and agents from any liability for injury, damage, liability, or claims arising from my child’s participation in these classes.  I understand that I may obtain copies of the Joy of Dance Policy Form at my schools office or by contacting Joy of Dance directly at info@joyofdance.org (703-503-0783).
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