Cotillion Club (5th grade)

North Little Rock Junior Cotillion

Cotillion Club (5th grade)

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$139.00

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6-week series meets after school in Jan & Feb 2025

ENTER STUDENT NAME *

Student Address

School Student Attends

Student's Date of Birth

Is there any special information we should know about your student? (ex. allergens)

Primary Parent Contact Name

Emergency Contact Name & Phone Number

I grant permission to use any photo or video of the student from the program in any manner without payment. I agree to indemnify Jr Cotillion of N. Little Rock, LLC from any claim that I may make because of the use of any likeness Select all that apply Yes, Image May be Used No, Image May NOT be Used

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