Dancer Intake Form

Please review the IAC Waiver and fill out the information below.

Dancer Information

Select an option

Female

Male

Birthday

Home Park District

Guardian 1 Information

Guardian 2 Information

Guardian 3 Information

Please inform IAC if any medical information taken may affect their time in dance class.

Allergies

Current Medications

Healthcare Provider & Phone Number

Please list any past or current physical limitations, injuries, and/or weaknesses that may affect the dancer:

Please list any sensory sensitivities the dancer may have:

If the dancer has a condition that may require special attention during class, please list with directions below (such as use of inhaler, insulin, etc.):

Click Here to View Participation Waiver

In signing this agreement, I acknowledge and represent that I have read and understand this Waiver of Liability Agreement. I hereby release Innovation Arts Connection from any and all liability described in the above. I agree to all above terms and grant permission for the participant to participate in Innovation Arts Connection classes and events.

Your Signature

Thanks for submitting!