Registration
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Welcome to Connectivity Dance! We cannot wait to welcome you into our studio for a trial class. Please fill out the following form so we can get you confirmed for a trial this month, and let our instructors know you are coming. If you have any questions, please reach to us at dance@connectivitydance.com or give us a call at 780-739-1142. We look forward to welcoming you into our studio and helping you Find your Fit! ~Connectivity Dance
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
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- denotes required fields
Family Information
First Name:
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Last Name:
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Type
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Aunt
Dancer
Father
Foster Parent
Grandparent
Guardian
Mother
Other
Parent
Sibling
Step-Parent
Uncle
Home Phone:
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Cell #:
Work #:
Email:
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(Emails are kept confidential)
Address:
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City:
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State/Prov:
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code:
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Emergency Contact Info (Please enter someone other than Primary Contact)
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Students entered below will be added to your family's account
Add New Student #1:
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Student's First Name:
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Last Name:
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Student Gender:
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Female
Male
Other
Birth Date:
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(format=mm/dd/yyyy)
Student Email:
School:
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Grade Level:
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10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
homeschool
kindergarten
pre-K
preschool
university
Class Accommodations Needed (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #2:
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Student's First Name:
*
Last Name:
*
Student Gender:
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Female
Male
Other
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
homeschool
kindergarten
pre-K
preschool
university
Class Accommodations Needed (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #3:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Other
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
homeschool
kindergarten
pre-K
preschool
university
Class Accommodations Needed (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Other
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
homeschool
kindergarten
pre-K
preschool
university
Class Accommodations Needed (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Other
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
10th grade
11th grade
12th grade
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
Adult
college
homeschool
kindergarten
pre-K
preschool
university
Class Accommodations Needed (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Questions/Options:
Have you been to Connectivity before?
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Yes
No
Class(es) Attending (Day/Time)
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Name of Participant (any nicknames they prefer to be called)
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Parent's Name
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Phone Number (during the class time)
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FOR TAP CLASS ONLY: Participants Shoe Size
Additional Information:
Trial Participation Waiver
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As the legal parent or guardian or participant over 18, I hereby give my approval for participation in physical activities offered through Connectivity Dance Ltd and all registered trademarks there of, which includes the Connectivity Skippers. I understand that while in the building or in the care of Connectivity Dance staff and volunteers, my child is to adhere to the studio policies, class requirements and all safety procedures. I furthermore release and hold harmless Connectivity Dance Ltd. it's owners, shareholders, administrators, instructors and volunteers from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while participating in any classes, programs or events while in or upon the premises or any premises under the control and supervision of Connectivity Dance Ltd., it's owners, administrators, instructors and volunteers or in route to or from any of said premises.
I've read the above and agree.
Enter your Full Name:
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