Registration - Cor Jesu Academy

Dance Team Clinic & Tryout Registration

Required

Student Namerequired

First Name

Last Name

CJA Graduating Class of

Address

City, State

Zip Code

Parent Namerequired

First Name

Last Name

Parent Phone Number

Parent Email Address

Medical and Emergency Releases

Must be completed for ALL participants.

By completing the following forms, I agree and understand that although Cor Jesu Academy has taken precautions to provide proper use and supervision for the Summer Camps at Cor Jesu Academy, it is impossible to guarantee absolute safety. Also, I understand that I share the responsibility for the safety of my child/myself during the activity and assume that responsibility. Further, I hold Cor Jesu Academy harmless and waive any claim which may arise against Cor Jesu Academy and/or its employees, agents and administrators.

My child, whom I have registered above, is covered by:

Insurance Company

Insurance Policy #

Emergency Contact Namerequired

First Name

Last Name

Emergency Contact Phone Number

Dance Clinic Fee

$40.00

Payment Information

Emailrequired

Provide an email address for the receipt.

Please complete captcha below to proceed to payment selection.

Please select a payment typerequired

Credit Card

Billing Addressrequired

Address

City

State/Province

Country

Zip/Postal Code

Cardholder Namerequired

First

Last

Expirationrequired

Month

Year