Kids Salsa Registration Form

KIDS SALSA @ UDT REGISTRATION

STARTING JANUARY 14 • WEDNESDAYS • 5-6P
Participant Information
Dancer's Name

First NameLast Name
Birth Date

MonthDayYear
AGE
Birth Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell 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 the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant 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 Uno Dos Tres Studio during the dance class. In exchange for the acceptance of said child’s candidacy by Uno Dos Tres Studeio, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Uno Dos Tres Studio and all its respective teachers, staff, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from dance lesson.In case of injury to said child, I hereby waive all claims against Uno Dos Tres Studio and its instructors and staff.
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.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

KIDS SALSA @ UDT REGISTRATION

Participant Information