2Xclusive Performing Arts Dance Detailed Registration Form

Dancer Information

Dancer Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Home Number

Cell Number

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Alt. Phone Number

Does the dancer have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the dancer prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement
I hereby give my approval for my child’s participation in any and all activities prepared by 2Xclusive Performing Arts during the selected days of rehearsals, events, & activities. In exchange for the acceptance of said child’s candidacy by 2Xclusive Performing Arts. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless 2Xclusive Performing Arts and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected rehearsals, events, & activities. In case of injury to said child, I hereby waive all claims against 2Xclusive Performing Arts including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Medical Release and Authorization As Parent and/or Guardian of the named dancer, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named dancer. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to 2Xclusive Performing Arts . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

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.

My Products

One Time Registration Fee (NEW DANCERS ONLY)NEW incoming dancers will pay a new dancer registration fee.

$100.00

Monthly Dance Tuition Monthly Tuition fee. Includes a FREE 2Xclusive T-shirt Shirt.

$400.00 2Xclusive Shirt Size

Weekly Tuition FeeDancers that register for WEEKLY TUITION.

$125.00

Daily Drop In (Non Performance/Child Care ONLY)Need last minute child care? 2Xclusive will allow daily drop in’s.

$50.00 Quantity

Total

$0.00