South West Modern Jive Registration Form

Email SouthWestMJ@protonmail.com
abn 83 938 147 706
Registration Form
This form must be completed in full in order to participate at any South West Modern Jive (SWMJ) events.
Student Personal Information
Full name

First NameLast Name
Email
example@example.com
Suburb & Postcode

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile phone
Format: (000) 000-0000.
Date of Birth

DayMonthYear
Date
Emergency Contact
Full name

First NameLast Name
Mobile phone
Format: (000) 000-0000.
Relationship to student
Dance History
How did you hear about South West Modern Jive?
Have you ever participated in Modern Jive before?
If so, what venues have you attended?
Have you ever participated in another style of dance?
If yes, what style?
Confidentiality Agreement
Information provided in this form will be kept strictly confidential and will only be used for registration, administration and communication purposes between South West Modern Jive and the student listed on this form.

South West Modern Jive respects your privacy and will not share your details with any third parties.
Housekeeping, Terms & Conditions & Dance Etiquette
I have observed all venue and South West Modern Jive housekeeping and agree to abide by all Terms and Conditions set out by South West Modern Jive. I agree to practice respectful dance etiquette to ensure the comfort, enjoyment and wellbeing of others while participating in any South West Modern Jive events. I understand that if I breach any Terms and Conditions or act in a manner which is inappropriate, South West Modern Jive reserves the right to refuse me entry to or remove me from any events.
Media
I agree that South West Modern Jive and its representatives may take photographs, videos or other media before, during and after classes or events, and these may be used in promotional material, including social media.
I agree that I am NOT permitted to share any photos, videos, content, lesson plans or any activities at South West Modern Jive without the express permission of the owners or representatives. This restriction includes posting of any material on any marketing or social media platforms.
Liability Waiver
I understand that dancing involves physical activity and inherent risks, including but not limited to, sprains, strains or falls. I understand that partner dancing also involves close physical contact with other people, including people of the opposite gender. I will respect instructors, students and all people at the venue and at all events. I will respect the property of students, of South West Modern Jive and of the venue. I accept personal responsibility for all of the risks associated with partner dancing at South West Modern Jive events and functions. I release South West Modern Jive, its owners, instructors and helpers from all liability and risk associated with dancing and other activities. I will ensure I am healthy and able to participate safely in lessons, dancing, and other activities at South West Modern Jive. I will remove myself from South West Modern Jive activities if I am unwell or cannot safely participate.
Date

DayMonthYear
Date
Student Signature
For students under 18 years of age only
I am the parent/guardian of the student. I grant permission for the student to participate in South West Modern Jive activities. I assume full responsibility for all risks, injuries and damages that may occur to the student. I will take reasonable steps to supervise the student at all times during activities.
Parent / Guardian Full Name

First NameLast Name
Parent / Guardian Signature
Should be Empty:

Registration Form

Student Personal Information

Emergency Contact

Dance History

Confidentiality Agreement

Housekeeping, Terms & Conditions & Dance Etiquette

Media

Liability Waiver

For students under 18 years of age only