Registration
Join Heidi Jones Eggert for this one day intensive on Adaptive Dance techniques.
Event:
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Type*
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
 
Address: *
City: * State: * Zip: *
Emergency Contact
Name, Phone, Relationship*
 
 
Students entered below will be added to your family's account
 
Questions/Options:
Promotional Code
 
Additional Information:
 
Liability Release
Please read this form carefully and be aware that in agreeing for yourself or on behalf of your child, you
acknowledge the risk of harm as a result of participating in any Cohesion Dance Project program.
Cohesion Dance Project offers dance programs to participants, including classes, rehearsals, and
performances. Dance is an activity in which, despite preparation, instruction, medical advice,
conditioning, and equipment, there is still a risk of injury, including but not limited to the following:
heart attack, stroke, and circulatory problems; bone and joint injuries; muscle strain and other muscle
injuries; foot problems.

As a participant or parent/guardian of a participant in the program, I acknowledge there are certain risks
of injury, and I agree to assume those risks of injury which I or my minor child may sustain as a result of
participating in any and all activities connected with or associated with such a program. In the event of
any emergency, I authorize Cohesion Dance Project officials to secure from any licensed hospital,
physician, or medical personnel any treatment deemed medically necessary for me or my minor child's
immediate care, and I agree I will be responsible for payment of any and all medical services rendered.
I have read and fully understand the above and acknowledge the risk of harm as a result of participating
in any Cohesion Dance Project program. I understand this agreement may not be modified orally.

I've read the above and agree.
 
Photo Release
I give permission for Cohesion Dance Project to use any photos or video of my child or myself (if over 18) for educational or promotional reasons.
I've read the above and agree.
 
Enter your Full Name: *   
 
Other Questions/Comments: