Sampler Registration

11217 West Forest Home Avenue, Suites 4&5 Franklin, WI 53132

Phone: (414) 425-7122

Fax: (414) 427-7112

Glencastleirishdancers.com
Family/Last Name
Address
City
State
Zip Code
Primary Email *All communication will be sent here*
example@example.com
Parent/Guardian 1 Name
Parent/Guardian 1 Cell Phone
Parent/Guardian 2 Name
Parent/ Guardian 2 Cell Phone

Dancer Information

Please fill out the following information per dancer. If registering only 1 dancer, skip dancers 2 and 3. If registering more than 3 dancers, please fill out an additional form.
Dancer 1 Name
Dancer 1 Birthdate

MonthDayYear
Date
Dancer 1 Class option:

3.5-5 year old (1:00-2:00pm)6+ year old (2:30-3:30pm)
Dancer 2 Name
Dancer 2 Birthdate

MonthDayYear
Date
Dancer 2 Class option:

3.5-5 year old (1:00-2:00pm)6+ year old (2:30-3:30pm)
Dancer 3 Name
Dancer 3 Birthdate

MonthDayYear
Date
Dancer 3 Class option:

3.5-5 year old (1:00-2:00pm)6+ year old (2:30-3:30pm)

Photo Use Authorization

I give permission to Glencastle Irish Dancers, Inc. to take and publish photographs, digital images and/ or videotaped images of me/my child for news, advertising and/ or promotional purposes in print and electronic media. I give permission for Glencastle Irish Dancers, Inc. to use photographs and/or videotaped images of me/my child taken by fellow Glencastle Irish Dancers families as well. I understand that I will not be compensated for any photograph or other images which may be used in this capacity. I agree that neither Glencastle Irish Dancers, Inc. nor its employees shall be liable for any claims, demands, actions, or causes of action of any sort whatsoever resulting from the publication of these photographs or other images. I do hereby release and discharge Glencastle Irish Dancers, Inc., their trustees, offices, employees, agents or servants from all such claims, demands, actions, or causes of action.
Parent/ Guardian Signature

Clear
Date

MonthDayYear
Date

Emergency/Health/Covid-19/Release of Liability

*One per dancer*
Dancer 1 Name
Dancer 1 Birthdate

MonthDayYear
Date
Please list the name of two individuals besides parents to call in case of an emergency:
Emergency Contact 1
Relationship 1
Phone 1
Emergency Contact 2
Relationship 2
Phone 2
Dancer 1: Any Health or Physical Restrictions (Asthma, allergies, Epi Pens, Inhalers, etc.)
In the event that the dancer needs to be transported to a hospital, which hospital do you prefer?
Every dancer is required to carry adequate medical insurance.

I certify that there are no health-related reasons or problems which preclude my/my child's participation in this activity or event. I will provide information from a medical professional should l/my child incur an injury where dance instruction needs to be limited.

On behalf of my minor child, myself, and my household members, I hereby give permission for my child to attend classes at Glencastle Irish Dancers, Inc. and I acknowledge that my/my child's participation in classesis voluntary.

I acknowledge and agree on behalf of my child and me that we shall:

Abide by Glencastle Irish Dancers, Inc. polices/procedures regarding illness Accept risks with COVID-19. Iagree to notify Glencastle Irish Dancers, Inc. and will not attend class if I/ he/she, or any member of my household, becomes ill.

I HEREBY WAIVE, RELEASE, AND DISCHARGE Glencastle Irish Dancers, Inc. and all divisions thereof of any and all liability and responsibility for injuries, sickness, pandemics, accidents, loss of property, death, natural disasters and/or acts of God incurred during participation in and/or instruction of classes, competitions, private instruction, performances or any activity l/my child may participate.

I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Dancer 2 Emergency/Health/Covid-19/Release of Liability

(Skip if only registering 1 dancer)
Dancer 2 Name
Dancer 2 Birthdate

MonthDayYear
Date
Please list the name of two individuals besides parents to call in case of an emergency:
Emergency Contact 1
Relationship 1
Phone 1
Emergency Contact 2
Relationship 2
Phone 2
Dancer 2: Any Health or Physical Restrictions (Asthma, allergies, Epi Pens, Inhalers, etc.)
In the event that the dancer needs to be transported to a hospital, which hospital do you prefer?
Every dancer is required to carry adequate medical insurance.

I certify that there are no health-related reasons or problems which preclude my/my child's participation in this activity or event. I will provide information from a medical professional should l/my child incur an injury where dance instruction needs to be limited.

On behalf of my minor child, myself, and my household members, I hereby give permission for my child to attend classes at Glencastle Irish Dancers, Inc. and I acknowledge that my/my child's participation in classesis voluntary.

I acknowledge and agree on behalf of my child and me that we shall:

Abide by Glencastle Irish Dancers, Inc. polices/procedures regarding illness Accept risks with COVID-19. Iagree to notify Glencastle Irish Dancers, Inc. and will not attend class if I/ he/she, or any member of my household, becomes ill.

I HEREBY WAIVE, RELEASE, AND DISCHARGE Glencastle Irish Dancers, Inc. and all divisions thereof of any and all liability and responsibility for injuries, sickness, pandemics, accidents, loss of property, death, natural disasters and/or acts of God incurred during participation in and/or instruction of classes, competitions, private instruction, performances or any activity l/my child may participate.

I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Dancer 3 Emergency/Health/Covid-19/Release of Liability

(Skip if only registering 1 or 2 dancers)
Dancer 3 Name
Dancer 3 Birthdate

MonthDayYear
Date
Please list the name of two individuals besides parents to call in case of an emergency:
Emergency Contact 1
Relationship 1
Phone 1
Emergency Contact 2
Relationship 2
Phone 2
Dancer 3: Any Health or Physical Restrictions (Asthma, allergies, Epi Pens, Inhalers, etc.)
In the event that the dancer needs to be transported to a hospital, which hospital do you prefer?
Every dancer is required to carry adequate medical insurance.

I certify that there are no health-related reasons or problems which preclude my/my child's participation in this activity or event. I will provide information from a medical professional should l/my child incur an injury where dance instruction needs to be limited.

On behalf of my minor child, myself, and my household members, I hereby give permission for my child to attend classes at Glencastle Irish Dancers, Inc. and I acknowledge that my/my child's participation in classesis voluntary.

I acknowledge and agree on behalf of my child and me that we shall:

Abide by Glencastle Irish Dancers, Inc. polices/procedures regarding illness Accept risks with COVID-19. Iagree to notify Glencastle Irish Dancers, Inc. and will not attend class if I/ he/she, or any member of my household, becomes ill.

I HEREBY WAIVE, RELEASE, AND DISCHARGE Glencastle Irish Dancers, Inc. and all divisions thereof of any and all liability and responsibility for injuries, sickness, pandemics, accidents, loss of property, death, natural disasters and/or acts of God incurred during participation in and/or instruction of classes, competitions, private instruction, performances or any activity l/my child may participate.

I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: