God's Little Angels Academy
GLA Academy
Where Students Believe, Achieve and Succeed

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

Name:*
Grade:*
Date of Birth:*
Parent/Guardian Name:*
Mailing Address:*
Home Phone:
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Cell Phone:
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E-mail:

TRANSPORTATION

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

In case of EMERGENCY, call:

Emergency Name:*
Emergency Phone Number:*
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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:*
Date:*

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