Registration forms can be mailed, faxed, or scanned and emailed.  You can print the registration form and send it to our office or pick one up at your school.

Jump Into Motion Dance Academy
Enrollment Form-Please Print Legibly
Class Location (Child’s School, Day Care, Evening, or Saturday Location)______________________________________________
Child’s Name____________________________________________________________________________________________
Birthday____/____/_______ Please Circle One (M) (F) Start Date____/____/______
Additional Child__________________________________________________________________________________________
Birthday____/____/_______ Please Circle One (M) (F) Start Date____/____/______
Additional Child__________________________________________________________________________________________
Birthday____/____/_______ Please Circle One (M) (F) Start Date____/____/______

Course Name________________________________Additional Courses _____________________________________________

_______________________________________________________________________________________________________

Parent or Guardian________________________________________________________________________________________

Phone #_________________________________________Other Phone #_____________________________________________
Street Address____________________________________________________________________________________________

City, State, and Zip Code____________________________________________________________________________________

Email (required)__________________________________________________________________________________________
*Monthly statements will be sent to your email.

(Does your child have any medical conditions their teacher should be aware of?  If so, please describe below:

_______________________________________________________________________________________________________

 

Required **Photo Release**  I, the undersigned, hereby give Jump Into Motion Dance Academy permission to use my child’s photograph for promotional purposes including flyers, posters, brochures, their websites, and other advertising.  I understand that my child’s name will never be used.  I also understand that I may not be notified when the picture is being used and I will not be financially compensated for the use of my child’s picture.

Please circle one.   Yes, I agree.   No, I do not agree.

Required **Liability Release**  I, the undersigned, hereby acknowledge that I have voluntarily applied for the services of Jump Into Motion Dance Academy.  I understand that Jump Into Motion Dance Academy, it’s teachers, contracted workers, or volunteers are not liable for any injury or damage of any kind caused during class or as a future result of instruction.  I also understand that my child’s school, day care, or any class location or organization or business associated with it are not responsible for any injury or damage of any kind caused during class or as a future result of instruction.  I have read all information on tuition and payment policies, course descriptions, and the and I fully understand all policies of Jump Into Motion Dance Academy.

Child’s/Children’s Name(s)___________________________Parent or Guardian______________________

Parent or Guardian’s Signature__________________________________________________Date____/____/______

You can pay with a credit card or check on our website through PayPal. 
We also accept checks or money orders, which can be sent to our PO BOX. 

 

This form and any payments are not to be handled by the dance instructor
or any staff at your child’s school, day care, or other location.  Please fax or mail this form to:

Jump Into Motion Dance Academy
PO BOX B Pendleton, IN 46064

(Please allow up to five business days for our office to receive and process new registration).

   First Month’s Tuition                            $________

   Annual Registration Fee                        $10.00_____ (Non-Refundable)
   Additional Childrens' Registration Fee   $________
   Total Amount Enclosed                        $_________

Phone 317-536-5085  Fax 317-536-6293  www.jumpintomotion.com  info@jumpintomotion.com