Registration
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Thank you for joining us in memory of our cherished dancer, Cailin Joyce.
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Family Information
First Name:
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Last Name:
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Address:
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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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Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
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Student's First Name:
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Birth Date:
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Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #3:
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Student's First Name:
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Last Name:
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Student Gender:
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Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #4:
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Student's First Name:
*
Last Name:
*
Student Gender:
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Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Add New Student #5:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Questions/Options:
Please list allergies/medical concerns/anything else we should know:
Additional Information:
Participation Agreement
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I hereby certify that my child is in normal health and capable of participating safely in Creative Movement Center's programs. I assume all risks and hazards incidental to the conduct of the program and hereby release CMC or its instructor from any and all claims for damages and injuries which may be sustained while participating in any and all activities connected with CMC.
I've read the above and agree.
Website/Advertising Waiver
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I give my permission for Creative Movement Center to use my child's photograph or likeness on our website or in connection with any advertising or news coverage of our events. Should I decline this permission, I hereby understand that I must notify CMC by emailing hayley@creativemovementcenter.com or alerting the front desk.
I've read the above and agree.
Payment
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I agree to pay $40 flat rate. If I am unable to attend all three classes, I can drop in for one or two classes.
I understand that all payments are non-refundable, and 100% of proceeds will be donated directly to the Joyce family to assist with Cailin’s medical expenses.
I've read the above and agree.
Enter your Full Name:
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ME
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MO
MS
MT
NC
ND
NE
NH
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NV
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OR
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RI
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Zip:
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