2025 Fall Dance
Step 1 of 3: Submit
Child's Name
*
Child's Birthday
*
Child's Age
*
Type of Dance
*
Select an option:
Ballet 2+
Hip Hop 5+
Child's Grade
*
Select an option:
Pre-K
K
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2
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Child's Parent/Guardian Name(s)
*
Child's Address
*
Parent/Guardian Phone Numer
*
CONSENT FOR EMERGENCY TREATMENT in the event I cannot be contacted in a medical emergency involving
my child, I authorize the Owen County Parks and Recreation to consent to all emergency medical care
proceedings to be rendered by a duly licensed health care provder or physician. I understand that the Owen
County Parks and Recreation does not provide insurance coverage for the above listed proram participant and
that I am responsible for my child's own personal insurance coverage. This care may be given under whatever
conditions necessary for the health and well being of my child
Insurance Information: Company Name
*
CONSENT FOR EMERGENCY TREATMENT
*
Select an option:
I agree
I disagree
Insurance information: Policy#
*
I agree that the Owen County Park and Recreation shall not be responsible for any personal injuries or
losses sustained by me or my registered child while on any premises, or as a result of any Owen County
Park and Recreation sponsored activities. I further agree to indemnify and save harmless the Owen
County Park and Recreation from any claims or demands arising out of any such injuries or losses.
Proof of insurance must be provided:
I understand that the fee must accompany the registration form for my child to be placed on the team
*
Select an option:
I agree
I disagree
Registration Fees
*
Select an option:
$110.00 - 11 week session ($110.00 USD)
Cash - Please bring money to first class
By Signing this form you are agreeing to the above waivers, policies and certifying information to be correct to the best of your knowledge.
Signature
*
Date:
Tuesday, 9 September 2025 (EDT)
Name:
Type your name to sign this document:
Typing name is equivalent to a handwritten signature
Scan this QR code with your phone:
*
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