ZOOM Registration Form

ZOOM Registration Form

Fill out the form carefully for registration
Dancer One *

First Name Last Name
Dancer One - D.O.B *

Day Month Year
Dancer ONE - date of birth
Dancer One Gender *
Dancer Two

First Name Last Name
Dancer Two - D.O.B

Day Month Year
Dancer TWO - date of birth
Dancer Two Gender
Dancer Three

First Name Last Name
Dancer Three - D.O.B

Day Month Year
Dancer THREE - date of birth
Dancer Three Gender
Home Address *

House Number / Street Address

Street Address Line 2

City

Postcode
1st Emergency Contact *

Name Last Name
1st Contact Number *
Mobile / Landline
1st Relationship To Dancer(s) *
Mother / Father / Grandparent etc
2nd Emergency Contact *

Name Last Name
2st Contact Number *
Mobile / Landline
2nd Relationship To Dancer(s) *
Mother / Father / Grandparent etc
E-mail *
example@example.com
Select Activity *

Cheer / Gymnastics (Tues) 6pm Dance / Fitness (Wed) 3:45pm Hip Hop (Wed) 5:20pm Yoga (Wed) 6:30pm Contemporary (Thurs) 6pm
How Did You Find STARPIC? *
Friend / Email / Facebook / Insta / Twitter / School etc
Additional Comments

0/150
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Online session rules:
1. A parent/adult must be in the room and directly supervising – do not carry out these online sessions/videos if a child or young person is home alone.
2. A large clear space to carry out moves safely – move anything obstructive out of the way to avoid injury or damage.
3. Be aware of your ceiling height.
4. Ensure the floor is not slippery or wet.
5. A bottle of water – please stay hydrated but keep any liquids a safe distance away.
6. Work within the skills being taught in the session only.
Disclaimer:
Parents/carers must always supervise children taking part to minimise risk of injury. Parents/carers accept all responsibility of monitoring use of this video in respect of any child/adult in their care.

You should understand that when participating in any exercise/coached online session, there is a possibility of physical injury. If you engage in this online session you agree that you do so at your own risk, are voluntarily participating in these activities, assume all risk of injury to yourself and those you are responsible for (i.e. children/family/others who watch this video), and agree to release and discharge both Starpic Project and the online coach from any and all claims or causes of action, known or unknown, arising as a result of this video/online sessions.

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I agree to the rules and disclaimer. *

Clear
Date

Day Month Year
Date
Hour Minutes
Should be Empty: