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: ___DAY______________________TIME_______________
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: ____________________________________________