After School Dance Registration

Please fill in the following form. This is a secured site so that all iformation entered is private and secure.

Name:*

First

Last

Grade:*

Date of Birth:*

Parent/Guardian Name:*

First

Last

Mailing Address:*

Street AddressCityStatePostal / Zip Code

Home Phone:

Area Code

Phone Number

Cell Phone:

Area Code

Phone Number

E-mail:

TRANSPORTATION

School Bus:

Tes

Other:

Name(s) of person(s) authorized to pick your child up from class:*

In case of EMERGENCY, call:

Emergency Name:*

First

Last

Emergency Phone Number:*

Area Code

Phone Number

MEDICAL INFORMATION

My child has the following condition(s), or is currently taking the following medications, which may limit his / her ability to perform certain dance moves injury(describe):

All of the information provided above is true and accurate, to the best of my knowledge.

I agree to accept responsibility for any medical costs which may result from his / her participation in this program.

I have read this release and indemnification agreement and understand its meaning. Being fully informed as to the risks associated with participation in this program, I hereby consent to the minor participating in this Program. I understand that my child will perform physical activity. I understand that my child will be transported from site to site using GLA Transportation. I understand that my child will be photographed and photo’s may be used for marketing purposes only.

Submission of this form implies that I understand that this is a legally binding contract, and I have read it and understand it.

Parent/Guardian Signature:*

First

Last

Date:*

GLA After School Dance Program Registration Form