Dancer Details

First Name:  
Middle Name:  
Last Name:   
Date of Birth (mm/dd/yy): Date of Birth (mm/dd/yy):

Program

Parent/Guardian Details

Parent/Guardian First Name:  
Parent/Guardian Middle Name:  
Parent/Guardian Last Name:  

Relationship to Student:

Supporting Documentation
Please upload supporting documentation from a licensed physician, physician's assistant, or nurse practitioner.

Statement of Exemption

By completing this form, I certify that different methods of vaccinating against COVID-19 have been considered, and that the following medical contraindication precludes any/all vaccinations for COVID-19.