Emerald City Stomp & Shake registration form

Emerald City Stomp & Shake 2023

Team Registration Form
Team name*
Studio Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Coach name*

First NameLast Name
contact Number*

Area CodePhone Number
E-mail*
coach Name

First NameLast Name
Contact Number

Area CodePhone Number
Cheer Stomp & ShakeDanceDrill/ Step
Cheer Stomp & Shake: HBCU CreativeCheer Stomp & Shake: Game DayCheer Stomp & Shake: Face-OffCheer Stomp & Shake: TraditionalDance: Creative SuperHeroes of Black History"Dance: Hip Hop "VS"Dance Field ShowDance: Coaches Stand BattleDance: Minis (4-9) Stand battleDance: Street Battle (All styles- combined)Drill/ Step: Captains SaluteDrill/ Step Judges StandDrill/ Step: Step Off
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Team roster.*
Last, First, age, DOB, Parent Name. Additional coaches can be listed here 2 max.
#of Dancers*
Informed Consent and Acknowledgement

I(Coach/ Director of the team above) hereby give my approval for my teams' participation in any and all activities prepared by Baile Dior Studios LLC and the Emerald City Stomp & Shake Competition on March 2023 @ location TBD. In exchange for the acceptance of said team’s candidacy by Baile Dior Studios LLC and the Emerald City Stomp & Shake Competition, I/We assume all risk and hazards incidental to the conduct of the activities and release, absolve and hold harmless Baile Dior Studios, The Emerald City Buck Down and all its respective officers, agents, and representatives from any and all liability for injuries to the said child arising out of participating in selected competitions auditions, practices, and performances.

In case of injury to said Dancer(s) listed above, I hereby waive all claims against Baile Dior Studios LLC and the Emerald City Stomp & Shake Competition. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
I agreeI disagree
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.

*I CERTIFY I AM OVER THE AGE OF 18 AND A LEGAL REPRESENTATIVE OF THE DANCE STUDIO/ TEAM AND ITS DANCERS LISTED ABOVE.
Coach/Director Signature*

Registration fee

Emerald City Stomp & Shake Registration - non refundable$100.00

Per team registration

Team(s)

Per Dancer Registration$15.00

Please enter the total number of people entering with your team must include support staff (max 3). DO NOT INCLUDE COACHES

Participants
Item subtotal:$0.00

Enter coupon

Total $0.00

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Emerald City Stomp & Shake 2023