Music & Dance Student Information Form 2022-2023

Please complete one form per family.  Add additional students' information as needed.

STUDENT ONE: Please complete information about the FIRST student enrolled in Burnt Hickory Music and Dance (music or dance classes). Additional students added below.
*Student 1 Name:
*Student 1 is enrolled in the:
*Student 1 Date of Birth:
*Student 1 Gender:
*Student 1 Age (as of 9/1/2022):
*Student 1 Grade (2022-2023):
Please list Student 1 Allergies or Medical Conditions.:
STUDENT TWO:  If needed, please complete information about the SECOND student enrolled in Burnt Hickory Music and Dance.  Otherwise, skip to the Parent/Household section below.
Student 2 Name:
Student 2 is enrolled in the:
Student 2 Date of Birth:
Student 2 Gender:
Student 2 Age (as of 9/1/2022):
Student 2 Grade (2022-2023):
Please list Student 2 Allergies or Medical Conditions.:
STUDENT THREE:  If needed, please complete information about the THIRD student enrolled in Burnt Hickory Music and Dance.  Otherwise, skip to the Parent/Household section below.
Student 3 Name:
Student 3 is enrolled in the:
Student 3 Date of Birth:
Student 3 Gender:
Student 3 Age (as of 9/1/2022):
Student 3 Grade (2022-2023):
Please list Student 3 Allergies or Medical Conditions.:
PARENT/HOUSEHOLD: Please provide parent and household information.
*Home Address (Street):
*Home Address (City):
*Home Address (Zip Code):
*Parent/Guardian 1 Name:
*Parent/Guardian 1 Cell Number:
*Parent/Guardian 1 Email:
Parent/Guardian 2 Name:
Parent/Guardian 2 Cell Number:
Parent/Guardian 2 Email:
*Church Attendance:
EMERGENCY CONTACTS: Please provide emergency contact information (in the event parents can not be reached).
*Emergency Contact Name (other than parents):
*Emergency Contact Cell Number:
AUTHORIZED PICKUPS: Please provide information for additional adults authorized to pick up Arts Academy student(s).
Authorized Pickup Adult 1 Name:
Authorized Adult Pickup 1 Cell Phone:
Authorized Adult Pickup 2 Name:
Authorized Adult Pickup 2 Cell Number:
PHOTO/VIDEO: BHBC Arts Academy may use student likenesses in various publications, including print, social media, website, or video archive.
*Photo/Video Release:
MEDICAL WAIVER: Dance classes and/or performances are active sports events which can involve physical contact with other participants, the floor, or equipment, and there is a risk of physical injury to the dancer.
*Medical Waiver and Release:
*Insurance Provider:
*Insurance Policy/Group Number:
*Student Physician:
PARENT CONTRACT:  Please read each statement below, then type name as signature to the Parent Contract.

1. Monthly tuition is due by the 1st of the month; a late payment fee of $10 will be added after the 15th.  If tuition payments cannot be made in a timely manner, a payment plan or other arrangments can be organized by contacting the Burnt Hickory Music and Dance Director.  After two months of non-payment, student(s) may be asked to suspend lesson/class attendance until balance is paid.
2. Students should arrive in plenty of time to prepare for lesson/class, including using the restroom and dressing appropriately, before class is scheduled to begin.  In addition, students should maintain appropriate equipment (dancewear, dance shoes, lesson books, etc.) required for lesson/class or performance.
3. All preschool or elementary-age students must be escorted to and from lesson/class each week; students must be picked up promptly at dismissal.  In the event parents are unable, arrangements should be made for another adult to drop off/pick up student(s).
4.  If parents choose to remain on the BHBC campus during a student's lesson/class, all parent/sibling waiting guidelines must be followed.  Children are not allowed to wander or play in the hallways, lounge areas, or coffee stations.  Outdoor play (supervised) is permitted on the front lawn or outside playgrounds; the indoor playground is closed.
5.  All communications from the Burnt Hickory Music and Dance staff, whether in print, email, text, or other media should be read to adequately prepare and equip students for lesson/class, performance, or other activity.
6. I understand that my child will be attending a ministry opportunity offered by Burnt Hickory Baptist Church. I understand that this program is not licensed by Bright from the Start: Georgia Department of Early Care and Learning. I also understand that this program is not required to be licensed and is operating under an exemption. I further acknowledge that Bright from the Start does not regulate or routinely inspect this program. I also acknowledge that I can contact Bright from the Start at 404-657-5562 or at www.decal.ga.gov if I have specific questions regarding this exemption.
*I have read and understand the Burnt Hickory Music and Dance Student Policies and, therefore, agree to abide by those policies and adhere to the above Parent Contract.  (Type name as signature.)