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 Risks related to dance
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: