Cannon Irish Dance

REGISTRATION FORM

 Dancer's Name:      ____________________________________________Dancer's Birthdate:  ______/______/______

Dancer's Name:      ____________________________________________Dancer's Birthdate:  ______/______/______

Dancer's Name:      ____________________________________________Dancer's Birthdate:  ______/______/______

NOTE THE CLASS(ES) YOU ARE REGISTERING FOR:  _____________________________________________________

CLASS LOCATION:  ________  BRUNSWICK                        __________  NORTH OLMSTED

Mother's Name:  _____________________________________________________________________________

Mother's Cell Number:  ___(_______________)____________________________________________________

Mother's Work Number:  ___(_______________)___________________________________________________

Father's Name:  _____________________________________________________________________________

Father's Cell Number:  ___(_______________)_____________________________________________________

Father's Work Number:  ___(_______________)____________________________________________________

Home Address:  _____________________________________________________________________________

City:  __________________________________________ State:  ____________  Zip:  _____________________

Home Phone:  ___(_____________)______________________________________________________________

E-Mail Address:  _____________________________________________________________________________

MEDICAL INFORMATION AND RELEASE FORM

Dancer’s Name:  _____________________________________________

Please indicate below any medical conditions, allergies, required medication, or any other important medical information for your child:  _______________________________________________________________________________________________

Doctor's Name:  _________________________                  Doctor's Phone:  _______________________________

Dentist's Name:  _________________________                 Dentist's Phone:  _______________________________

Preferred Hospital:  ______________________                

Hospital Phone:  _______________________________
EMERGENCY CONTACTS:

Please list a minimum of two emergency contacts for your child:

Name:  _______________________  Phone:  _____________________  Relationship:  __________________________

Name:  _______________________  Phone:  _____________________  Relationship:  __________________________

Name:  _______________________  Phone:  _____________________  Relationship:  __________________________

Parent / Legal Guardian Signature:  _____________________________________________

PHOTO RELEASE FORM

Dancer’s Name:  _____________________________________________

By signing below, I grant permission for photos of my child in association with the Cannon School of Irish Dance to be used on the School website, in promotional materials and any other areas as it relates to the Cannon School of Irish Dance.  By declining this photo release, I understand that my child may be excluded from group photos for this reason.

I grant permission for my child(ren) to be photographed with the Cannon School of Irish Dance and for the photos to be used as described above.

Parent / Legal Guardian Signature:  ____________________________________________

SIGN BELOW IF YOU DO NOT GRANT PERMISSION FOR YOUR CHILD TO BE PHOTOGRAPHED.

Parent / Legal Guardian Signature:  ____________________________________________