Registration forms can not be sent online.  You can print the registration form and send it to our office or pick one up at your school.  If you are signing up for evening classes and do not have access to a printer, you can see your child's instructor or contact our office and we can send you one.

Jump Into Motion Dance Academy
Enrollment Form-Please Print Legibly
Class Location (Child’s School, Day Care, Evening, or Saturday Location)______________________________________________
Child’s Name____________________________________________________________________________________________
Birthday____/____/_______ Please Circle One (M) (F) Start Date____/____/______
Additional Child__________________________________________________________________________________________
Birthday____/____/_______ Please Circle One (M) (F) Start Date____/____/______
Additional Child__________________________________________________________________________________________
Birthday____/____/_______ Please Circle One (M) (F) Start Date____/____/______

Course Name________________________________Additional Courses _____________________________________________

_______________________________________________________________________________________________________

Parent or Guardian________________________________________________________________________________________

Phone #_________________________________________Other Phone #_____________________________________________
Street Address____________________________________________________________________________________________

City, State, and Zip Code____________________________________________________________________________________

Email (required)__________________________________________________________________________________________
*Monthly statements will be sent to your email.

(Does your child have any medical conditions their teacher should be aware of?  If so, please describe below:

_______________________________________________________________________________________________________

Required **Photo Release**  I, the undersigned, hereby give Jump Into Motion Dance Academy permission to use my child’s
photograph for promotional purposes including flyers, posters, brochures, their websites, and other advertising.  I understand that
my child’s name will never be used.  I also understand that I may not be notified when the picture is being used and I will not be
financially compensated for the use of my child’s picture.

Please check one.  ? Yes, I agree.  ? No, I do not agree.

Child’s/Children’s Name(s)___________________________Parent or Guardian_________________________________________

Parent or Guardian’s Signature_____________________________________________________________Date____/____/______

Required **Liability Release**  I, the undersigned, hereby acknowledge that I have voluntarily applied for the services of
Jump Into Motion Dance Academy.  I understand that neither Jump Into Motion Dance Academy, it’s teachers, contracted workers,
or volunteers are not liable for any injury or damage of any kind caused during class or as a future result of instruction.  I also understand
that my child’s school, day care, or any class location or organization or business associated with it are responsible for any injury or
damage of any kind caused during class or as a future result of instruction.  I have read all information on tuition policies, course
descriptions, and the entirety of this form and I fully understand all policies of Jump Into Motion Dance Academy.

Child’s/Children’s Name(s)___________________________Parent or Guardian_________________________________________

Parent or Guardian’s Signature_____________________________________________________________Date____/____/______ 

You can pay with a credit card or check on our website through PayPal. 
We also accept checks or money orders, which can be sent to our PO BOX. 

This form and any payments are not to be handled by the dance instructor
or any staff at your child’s school, day care, or other location.  Please fax or mail this form to:

Jump Into Motion Dance Academy

PO BOX B

Pendleton, IN 46064

(Please allow up to five business days for our office to receive and process new registration).

   First Month’s Tuition                            $________

   Annual Registration Fee                        $8.00_____ (Non-Refundable)
   Additional Childrens' Registration Fee   $________
   Total Amount Enclosed                        $_________

Phone 317-536-5085  Fax 317-536-6293  www.jumpintomotion.com  info@jumpintomotion.com