Mckeon Dance and Gymnastics  
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(508) 473-8166

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Account Information

Mother's First:      Mother's Last:

Home Phone #      Cell Phone #:      Work #:

Mother's Employer:      Mother's email address:

Father's First:      Father's Last:

Home Phone #      Cell Phone #:       Work #:

Father's Employer:      Father's email address: *

Family Address:      City:      State:      Zip:

Emergency contact name:      Phone number:

Relationship to Student:      Cell #:


Health Insurance Carier :      Subscriber# :

Choice of Hospital:      Primary physician:

Medical Conditions:


1st Student's Information
Last Name:      First Name:      D.O.B.

Class Name:      Class Day/Time:

2nd Student's Information
Last Name:      First Name:      D.O.B.

Class Name:      Class Day/Time:

3rd Student's Information
Last Name:      First Name:       D.O.B.

Class Name:      Class Day/Time:


Liabilty and Release Form (Please read carefully and sign as indicated)

In consideration of allowing the previously-declared participant(s) to begin participation in McKeon Center activities, while on the premises and property of said Center, the undersigned, for themselves, and/or being the legal and acting guardian of participant, acting for themselves and on behalf of the participant, release and hold harmless Gym I & II, Inc., a Massachusetts Corporation D/B/A McKeon Dance & Gymnastics Center, its owners, officers, employees, and agents of and from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises upon which McKeon Center is conducted, or any premises under the control and supervision of Gym I & II, Inc., a Massachusetts Corporation D/B/A McKeon Dance & Gymnastics Center., its owners, officers, employees, or agents or in route to or from any of said premises, or while at any premises or place when activities sponsored by or participated in by Gym I & II, Inc., a Massachusetts Corporation D/B/A McKeon Dance & Gymnastics Center, its owners, officers, agents, or employees.

Assumption of Risk
Participation in physical activities can involve motion, rotation, and height in a unique environment and as such carries with it a certain assumption of risk. The undersigned and the participant(s) choose to voluntarily enter upon said premises under the control of said corporation, knowing their present condition and knowing that said condition may become more hazardous and dangerous during the time the participant or the undersigned is upon said premises. The undersigned and the participant(s) voluntarily assume any and all risks of loss, damage, or injury that may be sustained by the participant(s) and/or the undersigned or any property owner by them while on or upon said premises described above. The corporation may but shall not be obliged to carry insurance on the participant(s), and the existence of insurance shall not change, alter, or increase the liability of the corporation to the participant and the undersigned or affect the terms of this Release. In signing this Release, the undersigned acknowledges:

a) That he/she has read thoroughly and understands completely, the terms of Registration and Release and signs it voluntarily.
b) That the undersigned signing either for themselves, or as Legal Guardian is, in fact, the true and legal guardian and has the consent of the participant.

Medical Release
The undersigned gives permission for the Gym I & II, Inc., D/B/A McKeon Dance & Gymnastics Center, owners, officers, employees, and/or agents to seek emergency medical treatment for the participant(s) in the event they are unable to reach any parent or guardian. The undersigned also agrees that they themselves will be responsible for any financial debt incurred by said action.

Marketing Release
Occasionally the McKeon Center uses photos or video of its students in print ads, on its website, or other marketing mediums. I understand that my child’s likeness may be used in such advertising. These images will be used for McKeon Center purposes only, and will not be given or sold to outside companies or individuals.

Payment Information
There is an annual registration fee due at the time of registration. This fee is based on the length of class and the number of family members registered. Tuition is due by the first of each month and is based on flat monthly rates. If you should receive five classes during the month instead of four there will be no extra charge although it will be considered a makeup for classes missed while McKeon Center is closed for holidays. We’ve found that during the course of a year this averages out nicely and is a far less confusing payment arrangement for everyone concerned. McKeon Center will send out a statement of account.

If accounts are paid after the tenth of the month there will be a $15.00 late fee applied to the account balance. If, however you need to make different payment arrangements please come to the business office and we’ll be happy to work something out. Accounts that become 30 days overdue will be considered grounds for collections action. There is a $25.00 returned check charge for any checks returned by the bank. I understand that if my check is returned by the bank, or I am late with payments, that McKeon Center will require automatic credit or debit card payments from that point forward.

No refunds will be given. A letter of credit will be issued for any credit amount on your account.

*A two-week written notice to the McKeon Center Business Office is required to discontinue a program, otherwise I will be charged for any unattended classes.

By checking this box, I acknowledge that I have read and understand the above information.

Parent/Guardian name:* Date:
* = required


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mckeon dance and gymnastics massachusetts VISIT US
3A Spaceway Lane
Hopedale, MA 01747
(508) 473-8166