Registration Application

Registration Application
Dancer Name:
Date of Birth

Month Day Year
Date
Age:
School
Grade
Dancer's Cell Phone:
Address:
Parent /Guardian
Cell phone#
Parent/Guardian Email Address
example@example.com
**Emergency contact Information: If parent/guardian can’t be reached (Must be 21 years of age
Emergency Contact
Relationship
Address
Home#
Cell #
Work #
Physicians Name
Phone
Insurance Provider
Other Insurance
Policy /Group#
Hospital Preference
Complete the following entirely. Please put N/A on line(s) that do not apply to your child.
a) My child has the following medical condition(s).
b) My child takes the following medication(s) regularly
c) My child has the following allergies
My signature below gives written permission for my child to participate in Dance Integrity Performing Arts Theatre.
Parent/Guardian Signature:

Clear
Parent/Guardian Name:
Relationship:
Acknowledgement of Receipt
I, the parent of
I have received the Parent Handbook for Dance Integrity Performing Arts Theatre. I have been given an

opportunity to read and review the contents therein. I understand that it is my obligation to be aware of

the policies contained within. I acknowledge to have read the terms of this handbook in its entirety. I

understand that is my responsibility to stay up to date on parent information, through email, group texts,

website or social media of Dance Integrity.

I understand that the policies and information described in it are subject to change at any time at the sole

discretion of Dance Integrity Performing Arts Theatre. With this knowledge, I agree to enroll my child in

Dance Integrity Performing Arts Theatre for the 2020-2021 dance season.
Parent/ Guardian Printed Name
DATE

Month Day Year
Date
Parent/Guardian Signature

Clear
Should be Empty:

Registration Application

Acknowledgement of Receipt