Registration
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Enjoy an evening out and let us entertain your kids! They will love our dance, pizza, snacks, games and so much more! Open to ages 3 to 12. $20 per person
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Father
Guardian
Mother
Other
Parent
Home Phone:
*
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Emergency Contact Info
*
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Nonbinary
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
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Primary Doctor:
Previous Dance Experience:
*
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Nonbinary
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
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Primary Doctor:
Previous Dance Experience:
*
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Nonbinary
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
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Primary Doctor:
Previous Dance Experience:
*
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Nonbinary
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
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Primary Doctor:
Previous Dance Experience:
*
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Nonbinary
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
college-freshman
college-junior
college-senior
college-sophomore
kindergarten
pre-K
preschool
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Primary Doctor:
Previous Dance Experience:
*
Questions/Options:
Does your child have any food allergies
*
Additional Information:
Release of Liability
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I hereby covenant and agree to release and hold harmless Platinum Dance Company from and against any and all liability, loss, damages, claims, or actions (including costs and attorneys fees) for bodily injury and/or property damage to the extent permissible by law, arising out participation in the Platinum Dance Company Cheer Tumbling or Dance. I understand participation in Platinum Dance Company CheerTumbling or Dance involves rigorous physical activity and risks of physical injury, and we assume these risks. I hereby give consent for emergency transportation and treatment in the event of illness or injury. I hereby accept responsibility for the payment of any emergency transportation or treatment on behalf of the participant. I further certify the participant is in good physical condition, and has no medical or physical conditions that would restrict his/her participation in this event.
I've read the above and agree.
Appearance Agreement
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I understand that PDC produces promotional material about its programs. I understand that as a participant, my child may be included in video tapes or photographs taken during the year. I hereby grant Platinum Dance Company, its successors, assignees, licensees, sponsors, television networks, and all other exhibitors, the exclusive right to photograph or video tape my child and further use my child's name, face, likeness, voice and appearance as a part of its advertising and promotions without reservation or limitation. In granting this license, I understand that Platinum Dance Company is under no obligation to exercise any of its rights, licenses, and privileges herein granted.
I've read the above and agree.
Enter your Full Name:
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