2018 GEE FAM DANCE STUDIO WORKSHOP Palo Alto

GEE FAM DANCE WORKSHOP

Dance Connection Palo Alto 11/10/18
Registration Fees will be processed through PayPal and must be paid in full in order to process registration online. YOU DO NOT need to have a PayPal account to use this system and may use credit card or debit card and check out as a "guest".

Only one Dancer may be registered at a time.
Dancer's Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender:*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail Address where you'd like to receive confirmation and information:*
Emergency and Medical Information
Please provide emergency contact.
1st Emergency Contact Name*

First NameLast Name
1st Emergency Contact Relationship:*
1st Emergency Contact Daytime Phone Number:*

Area CodePhone Number
Liability/Photo/Video Release
I, as the registered am 18 or over, or I am a parent or legal guardian of the registered who is currently under the age of 18, grant permission for the registered Dancer to attend the GEE FAM Dance Convention and also do hereby release all GEE FAM instructors/faculty and Pacific Arts Complex from any and all liability or responsibility due to any injury that he/she/I may incur as the result of, or arising in any way from participation in activities at or under the direction of GEE FAM faculty. I am fully aware and consent to accept these risks and voluntarily agree to allow his/her participation in activities. If I cannot be consulted in an emergency, I hereby give permission to the physician selected by a representative of GEE FAM Dance Convention to hospitalize, secure treatment for, and to order injections, anesthesia, and/or surgery for the person named above. I understand that Pacific Arts Complex only carries secondary insurance and that I will take primary responsibility for any fees or charges at any clinic, facility, or hospital arising from treatment of injury or illness. I furthermore understand GEE FAM Dance Convention faculty will take photographs and or videos of participants during its activities or events. I grant permission without compensation that these photographs or videos may be used in publications, presentations, websites or promotion of GEE FAM Dance Convention or Pacific Arts Complex. GEE FAM Dance Convention or Pacific Arts Complex will not identify me or my child by name, or release any other personal information without additional written permission from me. I understand and acknowledge that GEE FAM has a no rufund for any reason policy.
Electronic Signature: By entering my name below, I accept the above conditions and releases. (You must be 18 years old or over to sign below.)*

First NameLast Name
Relationship To Registered Dancer:*
Current Date:*

MonthDayYear
Payment
For Security, type the message seen below:*
Click the box below before hitting submit*
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Gee Fam Workshop cost$110.00

Total $0.00
Upon completion of filling in all areas of form, click "Submit Form". You will then be taken to PayPal where you will submit payment and the registration process will be completed. Only one Dancer may be registered at a time. You may click "Print Form" to print a copy of this form. Do you have questions or need help with online registration? Email geefamdance@gmail.com and we will be happy to help you!
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GEE FAM DANCE WORKSHOP

Emergency and Medical Information

Liability/Photo/Video Release

Payment