Performing Hearts

How did you hear about the Open House? *
Jefferson Township Flyer Email from Peforming Hearts Friend Family Member Performing Hearts Web Site Newspaper Advertisement Other - please state in message field below

Parent / Guardian First Name *


Parent / Guardian Last Name *


Parent / Guardian Email *


Parent / Guardian Home Phone *


Parent / Guardian Work Phone


Parent / Guardian Cell Phone


Address *


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Relationship to Child: *
Mother Father Legal Guardian Grandparent Aunt/Uncle Other Relative

Child's Full Name: *


Child's Birthday (mm/dd/yyyy) *


Age (attach a copy of birth certificate or send/bring to office) *


Gender *
Female Male

Child's Current School *


Grade Level *
Preschool Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade College Freshman College Sophomore College Junior College Senior

Medications *


Disabilities *


Allergies *


Primary Doctor Name and Phone *


Please Indicate any Type of Assistance Child May Need *


Hospital Preference *


Open House -- Saturday, June 5th, 8:45am - 9:45am

Summer Dance Session I: 5 days, July 12-16, 10am – 11am

Summer Dance Session II: 5 days, August 2-6, 10am – 11am

After School Dance: 11-week session, Wednesdays, Sep. 8 - Nov. 17, 4:00pm - 5:00pm

Assumption of Risk and Release of Liability
I, the undersigned parent/guardian of the registrant/participant, a minor (or individual for who I have legal responsibility), agree that the child/participant named above and I will abide by the rules and regulations of the Jefferson Township Recreation Department and its affiliated organizations (including the Dance Academy of North Jersey, its owners and operators) and sponsors. I recognize the possibility of physical injury associated with dance and all recreational activities; and, in consideration of the Participant's participation, I do hereby waive, release, absolve, indemnify, and agree to hold harmless the Township of Jefferson, the Jefferson Township Recreation Department, its supervisors, employees and all program volunteers, as well as other persons (including the Dance Academy of North Jersey, its owners and operators) connected with Jefferson Township including the owners and operators of the facilities used for activities, against all claims, liabilities, and damages arising out of or in connection with the Participant’s participation in this program. *

Medical Emergencies
The undersigned gives permission to the Jefferson Township Recreation Department and its affiliated organizations and sponsors (including the Dance Academy of North Jersey, its owners and operators) to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or condition and/or declare the participant to be in good physical and mental health. Please be advised that any injury must be reported immediately to the Participant’s instructor or program supervisor. All insurance claims are to be processed through Participant’s family/guardian or personal coverage first before being submitted to Jefferson Township. *

Acknowledgement of Understanding
The Participant/Student and Parent(s) or Guardian(s) have read and fully understand the terms of this agreement, including the sections labeled Assumption of Risk and Release of Liability and Medical Emergencies. Furthermore, the undersigned understands that Participant/Student is giving up substantial rights, including the right to compensation for injury resulting from ordinary negligence. The undersigned Participant and Parent(s) or Guardian(s) acknowledge that you are signing the agreement freely and voluntarily, and intend your signatures to be a complete and unconditional release of liability to the greatest extent allowed by law in the State of New Jersey. In signing this waiver of liability as Parent or Guardian, you acknowledge that you are consenting to the Participant's participation in Jefferson Township's Performing Hearts Challenger Dance Program held at The Dance Academy of North Jersey and acknowledge that you understand that any and all risks, including that of ordinary negligence, whether known or unknown, are expressly assumed by the Participant and Parent or Guardian and all claims, whether known or unknown, are expressly waived in advance. *

Enter Your Full Name *


I've Read the Disclaimers Above and Agree; and I HEREBY CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE AND GIVE PERMISSION FOR MY CHILD (PARTICIPANT NAMED ABOVE) TO PARTICIPATE IN THE ABOVE DESCRIBED DANCE PROGRAM (by entering my name above and checking each paragraph above) *

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