En Pointe SLV - Dance Workshops

En Pointe Dance & Fitness - SLV Registration Form

Please make sure your dancer brings a snack, water, wears comfortable clothes or dance clothes. If your child has dance shoes please bring them, otherwise they can wear socks. Please no black or colored soled shoes. Dance Workshops: $75
Dancer Information
Name

First NameLast Name
Birth Date

MonthDayYear
Previous Dance Experience
Dance Workshops
Parent/Guardian Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is your child prescribed an inhaler or epi-pen? 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 by En Pointe Dance & Fitness - SLV during the selected workshop. In exchange for the acceptance of said child’s candidacy by En Pointe Dance & Fitness-SLV , I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless En Pointe Dance & Fitness-SLV 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 camp sessions.

In case of injury to said child, I hereby waive all claims against En Pointe Dance & Fitness-SLV including all teachers, counsurs and affiliates, all participants, and, if applicable, owners and lessors of premises used to conduct the event.
I understand that dance workshop payments are non refundable, but can be transfered to other activities at the dance studio.
Medical Release and Authorization

As Parent and/or Guardian of the above named child, 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.

Permission is also granted to the En Pointe Dance & Fitness-SLV and its affiliates including teachers, counselors and and staff for minor injury treatmentm, or emergeny medical treatment prior to the child’s admission to the medical facility if deemed necessay.

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.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Confirmation

BY ACKNOWLEDGING AND SIGNING ABOVE, 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.
Should be Empty:

En Pointe Dance & Fitness - SLV Registration Form

Dancer Information