NRG Dance Membership Form 20/21

Please complete this form - All sections with a red star are mandatory. Any problems please contact Tracy on 07918907241

Parent & Emergency Contact Information
Parent/Guardian Name *
Relationship to Child *
Parent/Guardian Home Tel No:
Parent/Guardian Mobile No: *
If you wish to provide details of a 2nd emergency contact please fill in the details below - if not leave blank
Name
Relationship to Child
Mobile No:

Medical information
Please detail any relevant allergies:
Does your child carry medication that might need to be taken during a dance class *

No Yes
If Yes please provide details of frequency and dosage
Drs Name *
Drs Surgery *
Dr Phone Number *

Area Code Phone Number

Parent/Guardian Policy Acceptance
Please tick the boxes below to confirm your acceptance and understanding of the following: *

Attendance Policy Uniform Policy Code of Conduct Health & Safety Statement Child Protection Policy Privacy Policy The requirement to set up a standing order - STANDING ORDER DETAILS ARE IN THE INFORMATION PACK AND WILL ALSO BE ATTACHED TO YOUR CONFIRMATON EMAIL FOR COMPLETING THE MEMBERSHIP FORM
Please tick the box below to confirm that you give media use rights permission - If you do not agree please confirm in writing via email and I will attach this to your Childs record *

Media Rights
Please tick the box below to confirm that you agree for the data provided in this form to be kept for a maximum of one year *

Data retention
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: