Samba Kids Registration Form

Samba Kids Class Registration Form

CASA SAMBA'S ***** SAMBA KIDS MEMBERSHIP/CLASS FREE REGISTRATION FORM. Please complete all fields.
Name*

First NameLast Name
E-mail*
Phone Number:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Class age start at 5 years old.
What Class will your child take

Children's Drumming and Stilt Walking Class Saturdays 9:30am to 12pmCapoeira Angola Kids Class Wednesday and Friday 6:00pm to 7pm
General health status

Allergies are special special medicationAsthma or breathing problemsAny recent severe injuries are broken bonesBelow please check your child's health status according to your knowledgefairgoodexcellent
Child 1 Name*
Your Child's Age

Child's Health

	1	2	3	4	5

1 is Worst, 5 is Best

Child 2 Name
Your Child's Age

Child's Health

	1	2	3	4	5

1 is Worst, 5 is Best

Child 3 Name
Your Child's Age

Child's Health

	1	2	3	4	5

1 is Worst, 5 is Best

Child 4 Name
Your Child's Age

Child's Health

	1	2	3	4	5

1 is Worst, 5 is Best

Emergency Contact:

Street Address

CityState / Province

Postal / Zip CodeCountry
Emergency Phone*
Where did you hear about us?*

A Friend or colleaugeInternetCasa Samba websiteYellow Pages
All Classes are FREE for Children under the age of 19

Class Membership Fees All classes- Adult Membership fee $250.00 per calendar year.
        Samba dance Class
        Samba Drumming class
        Capoeira Angola classes

Samba Drum & Dance classes   only- Adult Membership fee $150.00 per calendar year

Capoeira Angola classes only - Adult Membership fee $150.00 per calendar year

Adult Class Fee $10.00 per class – or $45.00/month
Membership Rules Agreement*

I have read, understood, and accepted the rules for membership.
MEMBERSHIP RULES

1. No alcohol beverages, Vaping and smoking is prohibited on the premises.

2. Anyone found under the influence will be asked to leave the premises

3. The NORDC – Annunciation Street Center is a drug-free zone.

4. Proper dance attire is required for class

5. Everyone is expected to conduct themselves in a reasonable manner, physical altercations will not be tolerated

6. No solicitation of members and/or parents

7. No videotaping or audio recording is allowed without permission.
Privacy Policy

The information you provided will only be used for our database and/or in the event of an emergency,. This information will not be shared or given out to anyone.
Privacy Policy Agreement*

I have read, understood, and accepted the PRIVACY POLICY for membership.
Terms and Conditions Agreement*

My child/children are in good health and hereby release Casa Samba and any of it members from and against any liability claims or demands for any injury or illness incurred at any class/ rehearsal and/ or CASA SAMBA event or performance for treatment of said injury or illness. I have read, understood, and accepted the TERMS AND CONDITIONS for membership.
Once you submit your application, we will contact you shortly to complete your
membership application.

Thank you!
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Samba Kids Class Registration Form

Privacy Policy