Somerset Dance Umbrella Registration Form

SOMERSET DANCE UMBRELLA Registration Form 2020
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Day/class attending*

Wednesday Junior JazzWednesday Senior JazzWednesday Advanced JazzWednesday Intermediate ModernWednesday Intermediate TapTuesday Beginners TapTuesday Beginners ContemporaryTuesday mid ContemporaryTuesday Advanced ContemporarySaturday Grade 5 ModernSaturday Flex n TrixSaturday Grade 2/3 Tap
Parent/Guardian Information
Name*

First NameLast Name
Home Tel Number*
Mobile phone Number*
E-mail*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*

Phone Number
Alt. Phone Number

Phone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the student prescribed any medication? If yes, please describe.
We will occasionally take photographs and video footage of students for teaching aids and for use in marketing and publicity material. Please select here to consent.
    *
Please select here if you consent to us contacting you by email
*
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE AND IN SUBMITTING THIS FORM I AGREE TO THE TERMS & CONDITIONS AS FOUND ABOVE AND THE POLICIES AS FOUND ON OUR WEBSITE
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

SOMERSET DANCE UMBRELLA Registration Form 2020