National League of Junior Cotillions

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Parent / Guardian 1 Salutation

Parent / Guardian 1 First Name *

Parent / Guardian 1 Last Name *

Parent / Guardian 1 Email Address *

Parent / Guardian 1 Email Address (Again)*

Parent / Guardian 1 Cell (or Preferred) Phone *

Parent / Guardian 1 Occupation

Parent / Guardian 2 Salutation

Parent / Guardian 2 First Name

Parent / Guardian 2 Last Name

Parent / Guardian 2 Email Address

Parent / Guardian 2 Cell (or Preferred) Phone

Parent / Guardian 2 Occupation

Photo and Video Release*

Please use the checkbox below to grant permission to the National League of Junior Cotillions and National League of Junior Cotillions Greater Miami Valley Chapter to use photos and/or videos taken at NLJC events for any legal use, including but not limited to newsletters, publicity, and web content, UNLESS I notify the director, Missy Mae Walters, in writing (with instructions and a photo of the child) before classes begin. The National League of Junior Cotillions will not use names or identifying information about students in any publication.

As the parent/guardian, I GIVE permission for images of my child(ren) to be used by The National League of Junior Cotillions in print or electronic materials as indicated above.

As the parent/guardian, I DENY permission for images of my child(ren) to be used by The National League of Junior Cotillions in print or electronic materials as indicated above.

Refund * There will be no refunds given except in the case of extraordinary circumstances such as moving or illness in fairness to the students who are on the waiting list.

Allergies * I understand the director will not be held responsible with respect to accommodating food-born allergies.

Note to Director

Payments I'll pay with PayPal* I'll pay with Venmo I'll pay by check

*an online handling fee of 5.4% will be added to PayPal payments.

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Director’s Home

National League of Junior Cotillions
Greater Miami Valley Chapter

Registration

2025-2026 Student Information

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2025-2026 Student #6 Information

About the Parents

Younger Siblings