Dancer Registration Form

Dancer Registration Form

ALL dancers are required to have registration filled out PRIOR to attending classes full time. A schedule may be found on our website, and will also be texted to the phone number you provide in the form. For any questions or concerns, please contact Emma at (346) 528-5490.
Dancer's Name:*
Contact Number for Dancer's Guardian (this will be the primary way of communication between you and ACTD):*
Contact Email for Dancer's Guardian:*
Dancer's Birthday:*

MonthDayYear
Date
Dancer's Age:*
What year does your dancer graduate (this question is only to help us determine how many seniors we will have in the upcoming season)?
Parent/Guardian First and Last Name:*
Dancer's Address (House Number, Street, City, State, and Zip Code):*
Allergies (if none, please type "None"):*
In Case of Emergency, please Contact (Name and Relation; Emergency Contact MUST be different from primary guardian):*
Emergency Contact Phone Number:*
Please enter a valid phone number.
Dancer's T-shirt Size:*

Youth SmallYouth MediumYouth LargeYouth XLAdult XSAdult SmallAdult MediumAdult LargeAdult XLAdult 2XAdult 3X
Dancer's Pant Size:*

Youth SmallYouth MediumYouth LargeYouth XLAdult XSAdult SmallAdult MediumAdult LargeAdult XLAdult 2XAdult 3X
The following set of questions are to help us get to know your dancer and place them in the best-fitting class with the best-fitting assistance. What name does your dancer prefer to go by at dance?*
What kind of school/classroom/work setting is the dancer currently in, if any?*
What is the dancer's official diagnosis, and how long has the dancer had this diagnosis?*
Does the dancer have any health concerns we need to be aware of (seizures, anxiety, etc.)?*
How does the dancer communicate (verbally, limited-verbally, non-verbally, sign language, etc.)?*
Describe the dancer's physical abilities (good range of movement, poor range of movement, extremely flexible, etc.):*
How does the dancer respond when working in groups with other people?*
Are there any disruptive behaviors that the dancer may exhibit? If so, what are they and what triggers them?*
Are there any things that calm the dancer when stressed (movie, phrase, song, etc.)?*
Which of the following does the dancer prefer as a praise during class?*

HugsHigh FivesFist BumpsOther
Is the dancer allowed to have stickers and/or snacks at the end of class?*

BothStickers OnlySnacks OnlyNeither
If the dancer is not actively participating in class and/or needs assistance:*

Provided Verbal Instruction OnlyProvide Demonstration OnlyProvide Gentle Physical Assistance OnlyTry verbal instruction first; if no response, try demonstration; if still no response, provide gentle physical assistance.Provide whatever is needed in the moment.
If my dancer wants to leave the classroom to take a break:*

AllowDon't Allow
If my dancer wants to go to the bathroom during class:*

AllowDon't Allow
If my dancer wants to leave the classroom the speak with a parent:*

AllowDon't Allow
What goals do you have for your dancer (mental, physical, social, etc.) while they participate in this program?*
The next set of questions will help instructors and volunteers learn more about your dancer. These things give us ways to communicate and make conversation with your dancer. What is your dancer's favorite song?*
What is your dancer's favorite movie?*
What is your dancer's favorite color?*
What is your dancer's favorite food?*
Is there a specific buddy you would like to be paired with your dancer (please keep in mind that we will do our best to accommodate but there are no guarantees this will be your dancer's buddy)?
Please use this space for anything else you'd like to share with the staff of A Chance to Dance.
Is there any part of the program that you wish was done differently or better?
As the legal guardian of (dancer’s name here), I authorize all A Chance to Dance staff to include directors, instructors, substitute teachers, assistants, and assigned buddies and volunteers to instruct, teach, and assist my dancer in order to fulfill the demands associated with dance class as they see fit and deem appropriate. I agree and pledge to follow the rules and regulations of A Chance to Dance and Barbie Rhodes Dance Studio. I also agree to having my dancer’s photo and/or likeness used indefinitely by the organization for advertising and marketing endeavors and waive all rights to such images. I understand that my financial account with A Chance to Dance must be kept in good standing. I understand that tuition is due on the first Friday of every month and a $5 late fee will be applied for each week that I am late on tuition, not to exceed $50. I understand that if my account accumulates $50in late fees without good reason, I may be asked to leave the program. In full understanding and with all regards to A Chance to Dance and/or Barbie Rhodes Dance Studio facilities or operating locale(s), the undersigned, now and forever, hereby releases and agrees to indemnify, and hold harmless these organizations inclusive of but not limited to their boards, owners, stockholders, agents, employees, volunteers, successors, and assigns from any and all liability, claims, or causes of action resulting from any loss, insult, or injury of any kind by the undersigned or any of the undersigned’s agents, dependents, patients, guests, clients, or visitors present as a result of the undersigned. This release, indemnification and hold harmless includes, but is not limited to, claims for personal injury and/or property loss and damage and all damages, costs, and attorney fees incurred as a result thereof, whether resulting from building defects, negligence, gross negligence, intentional acts, or omissions of A Chance to Dance (class or organization), Barbie Rhodes Dance Studio, their employees, assistants, volunteers, the undersigned, or otherwise. I understand that our volunteer staff may or may not receive any specific, legal, medical, official, or formal training and/or education through A Chance to Dance. All training conducted will be for informative purposes only. The dancer’s legal guardian will be present and have overall responsibility of their dependent’s safety, health, and welfare during the entire period of dance instruction, for each class, rehearsal, and performance. In addition, I understand that if my dancer has certain health concerns, I may not, under any circumstances, leave the premises in case of a medical emergency. I understand that while dancing with A Chance to Dance and Barbie Rhodes Dance Studio in class, rehearsal, and performances, my dancer(s) may be at risk of physical illness or injury (minimal, serious, catastrophic, and/or death), and I acknowledge that I am assuming risk or illness or injury by allowing my dancer to dance with A Chance to Dance and Barbie Rhodes Dance Studio. I am aware that this medical waiver and release releases A Chance to Dance and Barbie Rhodes Dance Studio from all liability, without limitation, from any illness or injury that may occur and acknowledges my voluntary and knowing assumption of the risk of illness or injury. I acknowledge that the volunteers associated with A Chance to Dance that are directly involved in the instruction of my dancer will receive the health information found on the health questionnaire provided by the legal guardian. I have signed this document voluntarily and of my own freewill. I will further states that I am at least eighteen (18) years of age, and am fully competent to sign this document.*

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